I need to survey about 25 adolescents on alcohol use in adolescents. Thank you all those who participate in the survey.
Age:
Sex: M/F
1. Tick what you believe to be the recommended intake of alcholic drinks for adult males and females per week.
MALES
a) <10
b) 11-14
c) 15-18
d) 19-25
FEMALES
a) 5-8
b) 9-12
c) 14-17
d) 18-22
2. Circle how many alcoholic drinks you consumed on each day/night of the week on average.
Monday 0 2 4 6 8 10+
Tuesday 0 2 4 6 8 10+
Wednesday 0 2 4 6 8 10+
Thursday 0 2 4 6 8 10+
Friday 0 2 4 6 8 10+
Saturday 0 2 4 6 8 10+
Sunday 0 2 4 6 8 10+
3. Where or from whom did you get your last alcholic drink.
Parents gave to you
From house without permission
brother or sister
friends
got someone to buy it
purchased with a fake i.d
4. do you believe the legal age for dirnking sould be lower or higher?
Unchanged
Higher ---> (AGE ________)
Lower ---> (AGE ________ )
5. Do your parents allow yout o drink
YES
NO
SOMETIMES
(If YES, where and why)
6. When you consume alcoholic beverage, where are you most likely to consume them?
at home
in a public place
house parites
in licensed premises with fake I.D
7. do you drink because you
like the taste
peer pressure
curiousity
other
all of the above
If other, please write why ____________________________________________________________________-
8. When you consume alcoholic drinks, what tpye are they? if you consume more than one type of tehse alcoholic drinks when you are drinking, please tick the ones you drink.
pre-mixed and packaged (ie cruisers)
individually mixed drinks (made by you or your friends)
beer
winne
straight spirits
9. Does advertising infleuce what you drink? If so, what form of advertising infleuces you the most?
television
magazines/newspaper (name:_________________________)
billboards
radio
10. How young were you when you had your first alcoholic drink?
<10
10-12
13-15
16-18
havent had one yet
11. While consuming alcoholic beverages have you ever participated ina ynthing that you regret?
Yes
No
12. Do you believe that alcohol is a bad infeluce on a persons behavior? If so, why?
Yes
No
(If YES, why? ______________________________________)
13. Have you ever consumed so much alcohol that you were sick?
Yes
No
14. Please tick the illnesses of which alcohool causes or contributes to.
cardiovasuclar conditions
kidney failure
brain degeneration
mental illnesses
liver cirrhosis
lung cancer
blindness
15. have you ever recieved a fine for udnerage drinking?
Yes
no
WOHOOOO, end of the survey.
Thank you for your time in participating in this survey, really much appreciated.
Age:
Sex: M/F
1. Tick what you believe to be the recommended intake of alcholic drinks for adult males and females per week.
MALES
a) <10
b) 11-14
c) 15-18
d) 19-25
FEMALES
a) 5-8
b) 9-12
c) 14-17
d) 18-22
2. Circle how many alcoholic drinks you consumed on each day/night of the week on average.
Monday 0 2 4 6 8 10+
Tuesday 0 2 4 6 8 10+
Wednesday 0 2 4 6 8 10+
Thursday 0 2 4 6 8 10+
Friday 0 2 4 6 8 10+
Saturday 0 2 4 6 8 10+
Sunday 0 2 4 6 8 10+
3. Where or from whom did you get your last alcholic drink.
Parents gave to you
From house without permission
brother or sister
friends
got someone to buy it
purchased with a fake i.d
4. do you believe the legal age for dirnking sould be lower or higher?
Unchanged
Higher ---> (AGE ________)
Lower ---> (AGE ________ )
5. Do your parents allow yout o drink
YES
NO
SOMETIMES
(If YES, where and why)
6. When you consume alcoholic beverage, where are you most likely to consume them?
at home
in a public place
house parites
in licensed premises with fake I.D
7. do you drink because you
like the taste
peer pressure
curiousity
other
all of the above
If other, please write why ____________________________________________________________________-
8. When you consume alcoholic drinks, what tpye are they? if you consume more than one type of tehse alcoholic drinks when you are drinking, please tick the ones you drink.
pre-mixed and packaged (ie cruisers)
individually mixed drinks (made by you or your friends)
beer
winne
straight spirits
9. Does advertising infleuce what you drink? If so, what form of advertising infleuces you the most?
television
magazines/newspaper (name:_________________________)
billboards
radio
10. How young were you when you had your first alcoholic drink?
<10
10-12
13-15
16-18
havent had one yet
11. While consuming alcoholic beverages have you ever participated ina ynthing that you regret?
Yes
No
12. Do you believe that alcohol is a bad infeluce on a persons behavior? If so, why?
Yes
No
(If YES, why? ______________________________________)
13. Have you ever consumed so much alcohol that you were sick?
Yes
No
14. Please tick the illnesses of which alcohool causes or contributes to.
cardiovasuclar conditions
kidney failure
brain degeneration
mental illnesses
liver cirrhosis
lung cancer
blindness
15. have you ever recieved a fine for udnerage drinking?
Yes
no
WOHOOOO, end of the survey.
Thank you for your time in participating in this survey, really much appreciated.