7/29/2019 Alcoholism Questionnaire

1/2

ALCOHOLISM AMONG COLLEGE STUDENTS QUESTIONNAIRE

This survey is designed to better understand the use of alcoholic beverages amongcollege students. Please be completely open and honest in providing information aboutyourself and your use of alcohol. Your individual responses will not be identified with you in

any way. All answers will be combined and only overall results reported.

1. Have you ever consumed alcoholic beverages?___ Yes ___ No If no, skip to question #9

2. Have you ever consumed five or more drinks in one sitting? For the purposes of this study, adrink is defined as a bottle of beer, a glass of wine, a wine cooler, a shot glass of liquor, a mixeddrink, or a similar drink containing alcohol.

___ Yes ___ No

3. Think back over the last two weeks. How many times have you consumed five or more drinks at

one sitting? ___

4. What is the average number of drinks you consume in a week? ___

5. To what extent has your alcohol use changed within the last 12 months?___ Increased___ About the Same___ Decreased

6. During the last 30 days, to what extent have you engaged in each of the following behaviors? Filin the blank. For example, if zero times put a 0, if one time put a 1; if 10 times put a 10, and so on.

Number of Times Refused an offer of alcohol? ___

Experienced peer pressure to drink? ___

7. Please indicate how often you have experienced the following due to your drinking during the lasyear (12 months)? Fill in the blank. For example, if zero times put a 0, if one time put a 1, if 10times put a 10, and so on.

Number of Times

Had a hangover? ___

Performed poorly on a test or important project? ___

Been in trouble with police, barangay officials or

other college authorities? ___ Damaged property, pulled fire alarm, etc.? ___

Got into an argument or fight? ___

Got nauseated or vomited? ___

Driven a car or motorcycle while being drunk? ___

Missed a class? ___

Thought you might have a drinking problem? ___

Experienced memory loss? ___

Done something you later regretted? ___

Been taken advantage of sexually? ___

7/29/2019 Alcoholism Questionnaire

2/2

Have taken advantage of another sexually? ___

Tried unsuccessfully to stop drinking? ___

Seriously thought about suicide? ___

Seriously tried to commit suicide? ___

Been hurt or injured due to your drinking? ___

8. For each of the following statements, indicate whether or not you believe alcohol has that effect?Put a check mark on your desired answer.

___ Enhances social activities___ Makes it easier to deal with stress___ Makes a connection with peers easier___ Facilitates male bonding

___ Facilitates female bonding___ Enables people to have more fun___ Makes food taste better

___ Interrupts your studying___ Messes up your physical living space (cleanliness, neatness, organization, etc.)

Classification Questions

9. What is your classification?___ Freshman ___ Senior___ Sophomore ___ Graduate Student___ Junior

10.What is your gender?

___ Female ___ Male

11. What is your age? ___

12.Binge drinking has been defined as consuming five or more drinks in one setting. Have you everconsumed alcohol in a manner that meets this definition?__ Yes __ No

If yes:a. Did you binge drink in high school? __ Yes __ Nob. Do you binge drink as a college student? __ Yes __ No

13.What is your marital status?__ Single __ Divorced__ Married __ Living with a partner, but not married__ Separated __ Widowed

Thank you for your participation.