How long have you been drinking alcohol? ? 0-4 yrs ? 5-9 yrs ? 10 yrs + 4. What is your usual daily consumption of alcohol? ? 0-3 times ? 4-7 times ? 8-11 times ? 12 times + 5. Is your family aware that you consume alcohol? ? Yes ? No 6. Are you allowed to consume alcohol? ? Yes ? No 7. Are you influenced to consume alcohol on a regular basis? If yes, state by whom. ? Yes ? No b) ___________________________________________ 8. How many persons are in your household? ? 2-4 persons ? 5-7 persons ? 8 persons + 9. Does everyone in your family consume alcohol? If no, state whom. ? Yes ? No b) ___________________________________________ 10.
Do you drink for special occasions? ? Yes ? No b) What special occasions do you mostly consume alcohol? Tick all that apply. ? Birthdays ? Anniversaries ? Graduations ? Holidays ? Parties 11. Is your family divided by the consumption of alcohol in the home? If yes, state how. ? Yes ? No b) ___________________________________________ 12. Does the use of alcohol affect your family relationship? ? Yes ? No 13. Do your family members often argue or quarrel because of the consumption of alcohol? ? Yes ? No 14. How often does your family argue or quarrel? ? 1-3 times ? 4-6 times ? 7-9 times ? 10 times + 15. Have you ever been drunk at any time?
If yes, state how long ago. ? Yes ? No b) ___________________________________________ 16. Have you ever been seriously drunk to the point of hospitalization or over-night stay? ? Yes ? No 17. Do you find comfort in consuming alcohol? If no, do not continue questionnaire. ? Yes ? No 18. How long can you stay without consuming alcohol? ? 1 hr ? 5 hrs ? 1 day ? 5 days ? 1 wk ? 5 wks ? 5 wks + 19. Do you plan to stop consuming alcohol in the future? ? Yes ? No b) Do you want help to stop consuming alcohol? ? Yes ? No 20. Have you sought help from family members or friends to stop consuming alcohol? ? Yes ? No Thank you for your co-operation!