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1. What year are you in college? (Required) |
Freshman
Sophmore
Junior
Senior
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2. How old are you? (Required) |
18
19
20
21
22
23
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3. What is your sex? (Required) |
Female
Male
Intersexed
Transgender
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4. What is your race? (Required) |
Caucasian
African American
Hispanic
Native American
Asian
Biracial
Multiracial
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5. One drink is considered 1 12oz beer, 1 oz 80 proof hard alcohol. What would you consider to be binge drinking? (Required) |
2-3/hour
4-5/hour
6-7/hour
7 +/hour
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6. How many nights per week would you say you drink? (Required) |
none
1-3
4-7
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7. Where do you most often drink? (Required) |
Dorms
Apartment/House
Bar/Club
Sorority/Fraternity
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8. At what age did you start drinking? (Required) |
12-15
16-18
19-21
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9. Do you drink with your family members? (Required) |
Yes
No
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10. Do you drink with your co-workers? (Required) |
Yes
No
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11. Do you drink with your roommates? (Required) |
Yes
No
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12. Do you drink with your friends? (Required) |
Yes
No
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13. Do you drink with you classmates? (Required) |
Yes
No
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14. Do you drink when you are stressed? (Required) |
Yes
No
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15. Do you drink when you are bored and have free time? (Required) |
Yes- on the weekends
Yes- on the week days
Yes-on the weekends and week days
No/Never
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16. Do you drink at parties? (Required) |
Yes
No
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17. Do you drink on special occasions? (weddings, birthday, family gathering, holidays, etc) (Required) |
Yes
No
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18. Do you drink when you get angry? (Required) |
Yes
No
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19. Do you drink when you are sad or depressed? (Required) |
Yes
No
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20. Do you drink to socialize? (Required) |
Yes
No
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21. Do you drink on the weekends? (Required) |
Yes
No
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22. Do you feel influenced by your friends to partake in drinking? (Required) |
Yes
No
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23. Do you feel influenced by your family members to drink? (Required) |
Yes
No
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24. Do you use cigarettes when you drink? (Required) |
Yes
No
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25. Do you use marijuana when you drink? (Required) |
Yes
No
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26. Do you use stimulants when you drink? (Required) |
Yes
No
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27. Do you use depressants when you drink? (Required) |
Yes
No
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28. Do you use opiates when you drink? (Required) |
Yes
No
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29. Do you use hallucinogens when you drink? (Required) |
Yes
No
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30. Do you parents drink? (Required) |
Yes
No
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31. Due to drinking, how many classes would you say you have missed within the past semester? (Required) |
None
1-3 classes
4-6 classes
7-9 classes
9 + classes
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32. Do you feel that your grades have suffered because of your drinking habits? (Required) |
Yes
No
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33. Do you feel that you get less sleep when you drink? (Required) |
Yes
No
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34. How many days of work do you typically miss in a week because of drinking? (Required) |
None
1-2 days
3-4 days
5-6 days
7 days
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35. Have you ever been hospitalized due to drinking? (Required) |
Yes
No
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36. Have you had any unplanned sexual contact when drinking? (Required) |
Yes
No
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37. Have you ever had any unwanted sexual/physical contact when drinking? (Required) |
Yes
No
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38. When you drink do you experience hangover symptoms? (nausea, vomiting , dizziness, headache, etc) (Required) |
Yes
No
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39. How much money do you spend on a typical night of drinking? (Required) |
No money spent
$1-$20
$21-$40
$41-$60
$61-$80
$81-$100
$100 +
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