My name is …

My (10 digit) mobile number is …

Please call me back on this number.

I drink …---Once a month or lessEvery weekMore than 3 times a week

I drink …---Mostly in the eveningMostly evenings, sometimes in the morningAny time of the day

When I don't drink I …---Feel nothingFeel restlessFeel restless & have tremors

In one drinking session, I have …---Less than 3 drinks3 to 5 drinksMore than 5 drinks

The next day after drinking I remember …---Everything from the previous nightSome things from the previous nightNothing from the previous night

My relatives & friends …---Don’t know of my drinking habitAre concerned of my drinking habitAre concerned & ask me to stop/reduce drinking

After drinking I feel …---NothingBad & guilty sometimesBad & guilty every time

Because of drinking, I have …---Never been late or missed workSometimes been late or missed workOften been late or missed work

Because of drinking, I have …---Never been injured or injured othersSometimes been injured or injured othersOften been injured or injured others

I have tried to quit drinking …---NeverOnceMore than once