Binge Drinking
1
. Are you Male or Female?
(Required)
Male
Female
2
. What is your age?
(Required)
Under 18
18-20
21-24
25 or older
3
. Do you know what Binge Drinking is?
(Required)
Yes
No
Somewhat
4
. Are you aware of the dangers of binge drinking?
(Required)
Yes
No
Somewhat
5
. What usually influences you to drink?
(Required)
Socializing
Depression
Boredom
Relaxation
Stress
Other
6
. How many times a week do you usually drink?
(Required)
1-3 times
4-6 times
7-10 times
Other amount
7
. On a typical night of drinking, how many drinks do you usually consume?
(Required)
1-3
4-6
7-10
Other amount
8
. Do you usually "pregame" before a night out drinking?
(Required)
Always
Sometimes
Never
Not sure
9
. Have you been drunk in the past week?
(Required)
Yes
No
Not sure
10
. Have you been drunk in the past month?
(Required)
Yes
No
Not sure
11
. Do you usually go out drinking with the intention of getting drunk?
(Required)
Always
Sometimes
Never
12
. Have you ever suffered memory loss from a night of binge drinking?
(Required)
Yes
No
Not sure
13
. How likely are you to engage in drug use when binge drinking?
(Required)
Very likely
likely
Somewhat likely
not likely
Never
14
. Do you think you are more likely to engage in sexual activity when drunk?
(Required)
Yes
No
Sometimes
15
. Have you ever drove a car while intoxicated? Even while "buzzed?"
(Required)
Yes
No
Not sure
16
. When you go out drinking, do you usually appoint a designated driver?
(Required)
Always
Sometimes
Not always applicable
17
. What do you think is the worst consequence from binge drinking?
(Required)
Getting arrested/Jail
Impaired Judgement
Personal Injury
Picking a fight/Domestic Violence
Other
18
. Do you think it's possible to have a good time without consuming alcohol?
Yes
No
Sometimes
19
. Five years from now, do you see yourself with similar drinking habits?
(Required)
Yes
No
Somewhat
20
. Do you think it would be easy to change your current drinking habits if you wanted to?
(Required)
Yes
No
Somewhat
