login
0
Cart
free shipping on all orders over $100
Managed Alcohol Cannabis Screening Survey
Step
1
of
16
6%
We have a few questions for you for screening purposes.
Are you currently part of a Managed Alcohol Program?
(Required)
Yes
No
Please tell us which location you belong to
(Required)
Drinkers' Lounge at PHS
Others
Gender
(Required)
Male
Female
Have you experienced the following in the last 6 months?
(Required)
2 or more presentations to ER for alcohol-related reasons
2 or more contacts with the police for alcohol-related reasons
Select All
How often do you use non-beverage alcohol?
(Required)
Daily
Weekly
Monthly
Less than monthly
Never
Regrettably, at this time, you do not qualify for our Cannabis Substitution Research, and we apologize for any disappointment.
You’re almost there. We have just a few more quick screening questions for you.
How often do you have a drink containing alcohol?
(Required)
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
How many standard drinks containing alcohol do you have on a typical day when drinking?
(Required)
1 – 2
3 – 4
5 – 6
7 – 9
10 or more
How often do you have six or more drinks on one occasion?
(Required)
1 – 2
3 – 4
5 – 6
7 – 9
10 or more
During the past year, how often have you found that you were not able to stop drinking once you had started?
(Required)
Never
Less than monthly
Monthly
Weekly
Daily or mostly daily
During the past year, how often have you failed to do what was normally expected of you because of drinking?
(Required)
Never
Less than monthly
Monthly
Weekly
Daily or mostly daily
During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?
(Required)
Never
Less than monthly
Monthly
Weekly
Daily or mostly daily
During the past year, how often have you had a feeling of guilt or remorse after drinking?
(Required)
Never
Less than monthly
Monthly
Weekly
Daily or mostly daily
During the past year, have you been unable to remember what happened the night before because you had been drinking?
(Required)
Never
Less than monthly
Monthly
Weekly
Daily or mostly daily
Have you or someone else been injured as a result of your drinking?
(Required)
No
Yes, but not in the past year
Yes, during the past year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?
(Required)
No
Yes, but not in the past year
Yes, during the past year
Regrettably, at this time, you do not qualify for our Cannabis Substitution Research, and we apologize for any inconvenience caused.
You qualify for our Cannabis Substitution Research. To proceed, please fill out fields below, and our researcher will contact you soon.
First Name
(Required)
Last Name
(Required)
Email
(Required)
Please note this is our main communication method.
This field is hidden when viewing the form
Total Score
This field is hidden when viewing the form
Threshold Score
×
login
×
What are you looking for?
