First Name
*
Last Name
*
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 drinks containing alcohol do you have on a typical day when you are drinking
*
0 - 2
3 or 4
5 or 6
7 - 9
10 or more
How often do you have six or more drinks on one occasion?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
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
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
*
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
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 another 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
In THE LAST 12 MONTHS, have you smoked cannabis?
*
Yes
No
Have you smoked cannabis before midday?
*
Never
Rarely
From time to time
Fairly often
Very often
Have you smoked cannabis when you were alone?
*
Never
Rarely
From time to time
Fairly often
Very often
Have you had memory problems when you smoked cannabis?
*
Never
Rarely
From time to time
Fairly often
Very often
Have friends or members of your family told you that you ought to reduce your cannabis use?
*
Never
Rarely
From time to time
Fairly often
Very often
Have you tried to reduce or stop your cannabis use without succeeding?
*
Never
Rarely
From time to time
Fairly often
Very often
Have you had problems because of your use of cannabis (argument, fight, accident, bad result at school, etc)?
*
Never
Rarely
From time to time
Fairly often
Very often
Audit total
Low Risk
Medium Risk
High Risk
Addiction Likely
Cast total
No Addiction Risk
Low Addiction Risk
High Addiction Risk
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