Page 1 of 1

Screening Questionnaire (Alc.)

Please answer honestly. Your details will be kept strictly confidential, and the identifiable details will be erased upon completion of the study.



Phone Number


Today's Date

Note: If you are filling the form using a mobile phone, please consider rotating the screen.

Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
1. How often do you have a drink containing alcohol?

1 or 2
3 or 4
5 or 6
7 to 9
10 or more
2. How many drinks containing alcohol do you have on a typical day when you are drinking?

Less than monthly
Daily or almost daily
3. How often do you have six or or more drinks on one occasion?
4. How often during the last year have you found that you were not able to stop drinking once you had started?
5. How often during the last year have you failed to do what was normally expected of you because of drinking?
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

Yes, but not in the last year
Yes, during the last year
9. Have you or someone else been injured because of your drinking?
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut it down?

Edinburgh Handedness Inventory - Short Form

Instructions: Please indicate your preferences in the use of hands in the following activities or objects.
Always Right
Usually Right
Both Equally
Usually Left
Always Left

Thank you for filling out the form. You will be contacted soon by the researcher.