CSAP's Prevention Pathways

Health Screening Survey (HSS), Revised

Check the appropriate answer.

1.	In the last 3 months, have you been dieting to lose weight?
	___YES	___NO
	IF YES: How many pounds have you managed to lose?
	___0	___1-3	___4-7	___8 or more
2.	In the last 3 months, have you performed physical activity or exercise in your leisure time at least 20 minutes without stopping, enough to make you breathe hard and/or sweat?
	___YES	___NO
	IF YES: On average, how many days per week have you been exercising?
	___1-2	___3-4	___5-6	___Everyday
3.	In the last 3 months, have you been smoking cigarettes at all?
	___YES	___NO
	IF YES: On average, how many cigarettes have you been smoking each day?
	___1-9	___10-19	___20-29	___30 or more
4.	In the last 3 months, have you been drinking alcoholic drinks at all (e.g., beer, wine, sherry, vermouth, or hard liquor)?
	___YES	___NO
	IF NO, go to question 5.
	IF YES, ANSWER 4a through 4c.
4a.	On average, how many days per week have you been drinking beer or wine coolers?
	___None	___1-2	___3-4	___5-6	___Everyday
	On a day when you have had beer or wine coolers to drink, how many glasses, bottles, or cans have you been drinking?
	___1-2	___3-4	___5-8	___9-14	___15 or more
	AND
4b.	On average how many days per week have you been drinking wine, sherry, or vermouth?
	___None	___1-2	___3-4	___5-6	___Everyday
	On a day when you have had wine, sherry, or vermouth to drink, how many glasses have you been drinking?
	___1-2	___3-4	___5-8	___9-14	___15 or more
	AND
4c.	On average how many days per week have you been drinking liquor (gin, vodka, rum, brandy, whiskey, etc.)?
	___None	___1-2	___3-4	___5-6	___Everyday
	On a day when you have had liquor to drink, how many single shots have you been drinking?
	___1-2	___3-4	___5-8	___9-14	___15 or more

5.	In the last 3 months, have you felt you should:
	a. Lose some weight	___No	___Sometimes	___Quite Often	___Very Often
	b. Cut down or stop smoking	___No	___Sometimes	___Quite Often	___Very Often
	c. Cut down or stop drinking	___No	___Sometimes	___Quite Often	___Very Often
	d. Do more to keep fit	___No	___Sometimes	___Quite Often	___Very Often
6.	In the last 3 months, has anyone annoyed you or gotten on your nerves by telling you to:
	a. Change your weight	___No	___Sometimes	___Quite Often	___Very Often
	b. Cut down or stop smoking	___No	___Sometimes	___Quite Often	___Very Often
	c. Cut down or stop drinking	___No	___Sometimes	___Quite Often	___Very Often
	d. Do more to keep fit	___No	___Sometimes	___Quite Often	___Very Often
7.	In the last 3 months, have you felt guilty or bad about:
	a. Your weight	___No	___Sometimes	___Quite Often	___Very Often
	b. How much you smoke	___No	___Sometimes	___Quite Often	___Very Often
	c. How much you drink	___No	___Sometimes	___Quite Often	___Very Often
	d. How unfit you are	___No	___Sometimes	___Quite Often	___Very Often
8.	In the last 3 months, have you been waking up wanting to:
	a. Exercise to keep fit	___No	___Sometimes	___Quite Often	___Very Often
	b. Smoke a cigarette	___No	___Sometimes	___Quite Often	___Very Often
	c. Have an alcoholic drink	___No	___Sometimes	___Quite Often	___Very Often
	d. Have something to eat	___No	___Sometimes	___Quite Often	___Very Often

9.	Now that you have completed this form, do you think you currently have:
	a. a weight problem	___Definitely	___Probably	___No
	b. a smoking problem	___Definitely	___Probably	___No
	c. a drinking problem	___Definitely	___Probably	___No
	d. a fitness problem	___Definitely	___Probably	___No
10.	Thinking back, would you say at any time in the past you had:
	a. a weight problem	___Definitely	___Probably	___No
	b. a smoking problem	___Definitely	___Probably	___No
	c. a drinking problem	___Definitely	___Probably	___No
	d. a fitness problem	___Definitely	___Probably	___No

Scoring: The HSS contains four subscales: one measuring amount of alcohol consumption (question 4 a, b, c¹), the CAGE questionnaire (questions 5-8²), one for self-perception of current problem with alcohol (question 9), and one for self-perception of past problems with alcohol (question 10). Consumption of 20 or more drinks per week, two or more positive responses to the four CAGE questions, self-perception of a current problem with alcohol use, or self-perception of a past problem with alcohol use indicates problem drinking.

Source: Fleming, M.F., and Barry, K.L. A three-sample test of a masked alcohol screening questionnaire. Alcohol and Alcoholism 1991, 26(1):81-91.

References

Kristenson, H., and Trell, E. Indicators of alcohol consumption: Comparisons between a questionnaire (Mm-MAST), interviews, and serum g-glutamyl transferase (GGT) in a health survey of middle-aged males. British Journal of Addiction 77, 297-304, 1982.
Mayfield, D.; McLeod, G.; and Hall, P. The CAGE questionnaire: Validation of a new alcoholism screening instrument. American Journal of Psychiatry 131:1121-1128, 1974.