Gender:




Age










Ethnic/Racial Group (select the one that best describes you)








Which campus are you from?












Treatment History for Alcohol:





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 started?







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







Have you or someone else been injured as a result of your drinking?





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





Are you currently taking any medications (over the counter or prescription)?




Name of Medication:



* A standard drink is one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits