* 1. You are:

* 2. How old are you?

* 3. How often do you drink?

* 4. Have you ever tried to cut back?

* 5. If you’ve ever tried to stop drinking, what was your primary motivation?

* 6. Do you ever worry alcohol is negatively affecting your life?

* 7. Have you ever done something you regret while drunk?

* 8. If you have done something you regretted while drinking, what was it? (Choose all that apply)

* 9. How often, on average, do hangouts with friends involve drinking?

* 10. You’re heading out to the bar with a group of friends. How many drinks are you likely to have?

* 11. How often do you have more than two drinks before you have sex?

* 12. How does alcohol impact your sex life? (choose all that apply)

* 13. In the past year, have you ever felt pressure from friends to drink more than you otherwise would?

* 14. Before a stressful situation (like a blind date or meeting his parents) do you ever have a drink by yourself to loosen up?

* 15. How likely are you to have a drink when you’re hanging out at home by yourself after work?

* 16. Aside from any physical symptoms, how do you normally feel after a heavy night of drinking?

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