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How often do you have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have four or more drinks on one occasion?

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected of you because of drinking?

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because of your drinking?

Have you or someone else been injured because of your drinking?

Has a relative, friend, doctor, or other health care worker been concerned about your drinking of suggested you cut down?

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Never

0-2

Never

Never

Never

Never

Never

Never

No

No

Monthly or less

3 or 4

Less than monthly

Less than monthly

Less than monthly

Less than monthly

Less than monthly

Less than monthly

2-4 times per month

5 or 6

Monthly

Monthly

Monthly

Monthly

Monthly

Monthly

Yes but not in the last year

Yes but not in the last year

2-3 times per week

7-9

Weekly

Weekly

Weekly

Weekly

Weekly

Weekly

4 or more times per week

10 or more

Daily or almost daily

Daily or almost daily

Daily or almost daily

Daily or almost daily

Daily or almost daily

Daily or almost daily

Yes, in the last year

Yes, in the last year

      0                     1                  2                  3                4

Have you ever been in treatment for an alcohol problem?           Never            Currently         In the past

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