Drinking Habits Survey

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Name
0

Date of birth
0

Gender
0

Occupation
0

Do you drink alcohol?
Yes

No
0

What sort of drinker are you?
Alcoholic

Heavy drinker

Binge drinker

Light drinker

Social drinker
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What do you typically drink?
Beers

Wines

Spirits

Other (Please specify)
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List your favorite alcoholic beverages

0 / 5000
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How often do you drink?
< Once a week

Once a week

2-3 times a week

4-6 times a week

Every day
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Where do you usually drink?
Office

Bar

Outdoors

Home

Events

Movie theater

Beach

Other (Please specify)
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How much do you spend a month on drinking?
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Is there a family history of alcoholism?
Yes

No
0

Please elaborate

0 / 5000
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Does anyone close to you drink heavily?
Yes

No
0

Please elaborate

0 / 5000