DBQR

Instructions: For each of the items below indicate the alternative that best
describes you or your behavior by circling the appropriate answer. Please
complete every item, making your best guess if you are unsure.

1. What type of alcoholic beverage do you consume most often when you
drink?

a. Beer
b. Wine
c. Mixed drinks (hard liquor and nonalcoholic mixer)
d. Straight drinks (hard liquor alone or with ice only)
e. other

2. On the average, how often do you consume alcoholic beverages of any

kind? (Note: Each "time" or drinking occasion must be separated by a
period during which you become completely sober again.)

a. Once a month or less

b. 2 or 3 times a month
c. Once a week
d. Twice a week
e. 3 or 4 times a week
f. 5 or 6 times a week
g. 7 or 8 times a week
h. 9-13 times a week
i. 14-20 times a week
j. 21 or more times a week

3. On the average, how many “drinks” do you have each “time” or on each
occasion when you do consume alcoholic beverages? (Note: one “drink”
= one 12 ounce beer or one 5 ounce glass of wine or one 1.5 ounce
shot of hard liquor, straight or with mixer.)

a. Less than one whole drink

b. One “drink”
c. 2 “drinks”
d. 3 “drinks”
e. 4 “drinks”
f. 5 “drinks”
g. 6 “drinks”
h. 7-9 “drinks”
i. 10-12 “drinks”
j. More than 12 “drinks”
4. About how long have you been drinking at your present rate?

a. 3 months or less
b. 3-6 months
c. 6-12 months
d. 1 year
e. 2 years
f. 3 years
g. 4 years
h. 5-7 years
i. 8-10 years
j. More than 10 years

5. What was your rate of alcohol consumptions before you established

your current level?

a. I did not drink at all then.

b. I used to drink much less.
c. I used to drink somewhat less.
d. I used to drink somewhat more.
e. I used to drink much more.

6. On the average, how often do you get at least “somewhat high” or

“somewhat intoxicated” from drinking alcoholic beverages?

a. Less than once a month (including never)

b. Once a month
c. 2 times a month
d. 3 times a month
e. Once a week
f. 2 times a week
g. 3 times a week
h. 4 times a week
i. 5-7 times a week
j. More than 7 times a week

7. When you do get “somewhat high” or “somewhat intoxicated,” how

many “drinks” does it usually take? (Remember: one “drink”=1beer, 1
glass of wine, or 1 single shot - straight or mixed.)

a. I have never felt somewhat high or intoxicated

b. 1 or fewer “drinks”
c. 2 “drinks”
d. 3 “drinks”
e. 4 “drinks”
f. 5 “drinks”
g. 6 “drinks”
h. 7-9 “drinks”
i. 10-12 “drinks”
j. More than 12 “drinks”
8. On the average, how often do you get “drunk”?

a. Less than once a month (including never)

b. Once a month
c. 2 times a month
d. 3 times a month
e. Once a week
f. 2 times a week
g. 3 times a week
h. 4 times a week
i. 5-7 times a week
j. More than 7 times a week

9. When you do get “drunk,” how many drinks does it usually take?
(Remember: one “drink” = 1 beer, 1 glass of wine, or 1 single shot –
straight or mixed.)

a. I have never been drunk

b. 1 or fewer “drinks”
c. 2 “drinks”
d. 3 “drinks”
e. 4 “drinks”
f. 5 “drinks”
g. 6 “drinks”
h. 7-9 “drinks”
i. 10-12 “drinks”
j. More than 12 “drinks”

10. What is the maximum number of drinks that you have consumed in one
drinking occasion? (Note: one “drink” = one 12 ounce beer or one 5
ounce glass of wine or one 1.5 ounce shot of hard liquor, straight or
with mixer.)

a. Less than one whole drink

b. 1 “drink”
c. 2 “drinks”
d. 3 “drinks”
e. 4 “drinks”
f. 5-6 “drinks”
g. 7-9 “drinks”
h. 10-14 “drinks”
i. 15-18 “drinks”
j More than 18 drinks

11. In comparison to the average person of your same age, sex, and body
weight, how well would you say you “hold your liquor”?

a. I can drink much less before I am affected.

b. I can drink somewhat less before I am affected.
c. I can drink about the same amount before I am affected.
d. I can drink somewhat more before I am affected.
e. I can drink much more before I am affected.