Assessment and Followup Questions

1. I would like to ask you some questions about your use of alcoholic beverages, like beer, wine, wine coolers, and hard liquor such as vodka, gin, and whiskey. Have you had a drink of alcohol in the past year?
   • No (interview ends) - 1
   • Yes (skip to 2) - 5
   • Unable to answer (interview ends) - 8
   • Refused to answer - 9


2. During the last week, did you have any drink containing alcohol?
   • No (skip to 3) - 1
   • Yes - 5

   I would like to know the number of alcoholic drinks you’ve had each day in the last week. Today is ________________________. Let’s begin with yesterday.

   How many drinks of beer, wine, or liquor did you have on (NAME DAY OF WEEK)?

   	Number of Drinks
   Sunday	____
   Monday	____
   Tuesday	____
   Wednesday	____
   Thursday	____
   Friday	____
   Saturday	____
   Sunday	____

   Fill in the number of drinks consumed on each of the 7 days prior to the interview. The total represents the total number of drinks per week.

   Note:	A single mixed drink	= 1 drink
   	A 12 oz. beer	= 1 drink
   	A shot of hard liquor	= 1 drink
   	A pint of hard liquor	= 11 drinks
   	A fifth of hard liquor	= 18 drinks
   	A 4 oz. glass of wine	= 1 drink
   	A pint of wine	= 5 drinks
   	A bottle of wine (40 oz.)	= 8 drinks



3. During the last 3 months, on days that you drank any alcohol, how many times did you drink four or more drinks in one day? ____

Source: Barry, K.L.; Oslin, D.W.; and Blow, F.C. Alcohol Problems in Older Adults: Prevention and Management. New York: Springer Publishing, 2001.