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About Us
Treatment Programs
Admission
Resources
Testimonials
Contact Us

Alcohol Misuse Survey

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Welcome To Your Alcohol Misuse Survey.

Alcohol Quiz

Email
This field is for validation purposes and should be left unchanged.
How often do you have a drink containing alcohol?*
- Never
- Monthly or less
- 2-4 times a month
- 2-3 times a week
- 4 or more times a week
How many standard drinks containing alcohol do you have on a typical day when you are drinking?*
- 1-2
- 3-4
- 5-6
- 7-9
- 10+
How often do you have six or more drinks on one occasion?*
- Never
- Monthly or less
- Two to four times a month
- Two to three times a week
- Four or more times a week
How often during the last year have you found that you were not able to stop drinking once you had started?*
- Never
- Monthly or less
- Two to four times a month
- Two to three times a week
- Four or more times a week
How often during the last year have you failed to do what was normally expected from you because of drinking?*
- Never
- Monthly or less
- Two to four times a month
- Two to three times a week
- Four or more times a week
How often during the last year have you had a feeling of guilt or remorse after drinking?*
- Never
- Monthly or less
- Two to four times a month
- Two to three times a week
- Four or more times a week
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?*
- Never
- Monthly or less
- Two to four times a month
- Two to three times a week
- Four or more times a week
How often during the last year have you been unable to remember what happened the night before because you had been drinking?*
- Never
- Monthly or less
- Two to four times a month
- Two to three times a week
- Four or more times a week
Have you or someone else been injured as a result of your drinking?*
- No
- Yes, But not in the last year
- Yes, During the last year
Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?*
- No
- Yes, But not in the last year
- Yes, During the last year
Name*
Email*
Phone*
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Address:

920 4th Avenue North
Great Falls, Montana 59401

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Contact

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Reception: (406) 727-8832

Fax Number: (406) 727-8172

Email: info@rehabrocky.com

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