Participant No.

Participant

alcoholreality
alcohol realitycheck
check(adult)

I heardMy
about
age: this event
 13–15by:
yrs 16–18 yrs Sex: My age:  under
19 yrs  19–24 yrs
 newspaper
article  newspaper
 19–24 yrs ad
 25+ yrs  TV  25–39 yrs  40–64 yrs
 radio  word of mouth  poster  65+ yrs
 other
What is a unit of alcohol?
Beer/Cider:
The three questions below refer to your 350 alcohol consumption in the past week, a useful indicator
ml or 12 oz
The three questions below refer
of your drinking pattern provided it was aattypical week.
5% alcohol Liquor highball/
to your alcohol consumption in cocktail: 50 ml or
A "unit
the pastofweek,
alcohol" (as in indicator
a useful Question 1 below) is equivalent to any of these: 1.5 oz shot of
• one regular-sized bottle of beer or cider (350 ml or 12 oz at 5% alcohol)
of your drinking pattern provided hard liquor at
40% alcohol
it was a typical week. A "unit of (50 ml or 1.5 oz shot of
• one regular highball or cocktail hard liquor at 40% alcohol)
Cider Small glass
• one small glass of wine (150isml or 5 oz at 12% alcohol) of wine:
alcohol" (or "standard drink") 150 ml
• one smalltoglass
equivalent of these:
any of sherry or port (100 ml or 3.5 oz at 18% alcohol) or 5 oz at
12% alcohol

Questionnaire
male  female 

QUESTIONNAIRE
1. How many units of alcohol, if any, have you had each day in the last week?
Record the number you consumed on the timeline below.
1. How many units of alcohol did you have each day in the last week?
Record the number you consumed on the timeline below.
7 days ago 6 days ago 5 days ago 4 days ago 3 days ago 2 days ago yesterday total
TOTAL
UNITS:
2. How
7 daysmany
ago times did
6 days you combine
ago 5 days ago drinking
4 days with
ago one or more
3 days ago of2 the
daysfollowing?
ago yesterday
• driving or using machinery
2. During • other situations where alertness is required
time(s) the last week, how many times did you drink
• use
• in situations of depressant
where substances,
mental alertness and/orincluding
physicalmedications
coordination(e.g., painkillers, sleeping pills, tranquillizers)
is required
• pregnancy or breastfeeding
(e.g., bicycling, driving or using potentially dangerous equipment, work, school,
3. Howsports,
many days,
mindingif any, in the past week did you find it difficult or uncomfortable to stop drinking once you started?
children)
In•other words, on how many days
in certain social situations suchdidasyou experience
against parentalanxiety or stress
guidance, at the
to cope thought of cutting yourself off from
with
the next drink?
being alone or in order to fit in TOTAL
• while using other drugs (e.g., energy drinks, marijuana, ecstasy, cocaine, or TIMES:
medications such as antidepressants, pain killers, sleeping pills)
•day(s)
when suffering from a serious physical or mental illness
• while pregnant or breastfeeding
3. How many times in the past week did you find it difficult or uncomfortable to stop TOTAL
Interpretation
drinking once you started? TIMES:
An on-site clinician will help you interpret your responses and provide you with take-home resource materials.

INTERPRETATION
An on-site clinician will help you interpret your responses and provide you with take-home resource materials.

Staff use:
Staff  Low risk
risk pattern  Increased
pattern  Increasedrisk
riskpattern High
pattern  Highrisk
riskpattern
pattern