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    Arc Questionnaire

    Uploaded by

    Janet Fernandez
    This document appears to be an alcohol screening questionnaire. It asks the participant for their age, sex, and how many units of alcohol they consumed each day over the past week. It also asks how many times they drank in situations that required alertness or coordination, and how many days they had difficulty stopping drinking once they started. The questionnaire will be interpreted by a clinician and take-home resources will be provided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Arc Questionnaire

    Uploaded by

    Janet Fernandez
    67 views1 page
    This document appears to be an alcohol screening questionnaire. It asks the participant for their age, sex, and how many units of alcohol they consumed each day over the past week. It also asks how many times they drank in situations that required alertness or coordination, and how many days they had difficulty stopping drinking once they started. The questionnaire will be interpreted by a clinician and take-home resources will be provided.

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    arc-questionnaire

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    This document appears to be an alcohol screening questionnaire. It asks the participant for their age, sex, and how many units of alcohol they consumed each day over the past week. It also asks how many times they drank in situations that required alertness or coordination, and how many days they had difficulty stopping drinking once they started. The questionnaire will be interpreted by a clinician and take-home resources will be provided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    67 views1 page

    Arc Questionnaire

    Uploaded by

    Janet Fernandez
    This document appears to be an alcohol screening questionnaire. It asks the participant for their age, sex, and how many units of alcohol they consumed each day over the past week. It also asks how many times they drank in situations that required alertness or coordination, and how many days they had difficulty stopping drinking once they started. The questionnaire will be interpreted by a clinician and take-home resources will be provided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Participant No.

    Participant

    alcoholreality
    alcohol realitycheck
    check(adult)

    I heardMy
    about
    age: this event
     13–15by:
    yrs 16–18 yrs Sex: My age:  under
    19 yrs  19–24 yrs
     newspaper
    article  newspaper
     19–24 yrs ad
     25+ yrs  TV  25–39 yrs  40–64 yrs
     radio  word of mouth  poster  65+ yrs
     other
    What is a unit of alcohol?
    Beer/Cider:
    The three questions below refer to your 350 alcohol consumption in the past week, a useful indicator
    ml or 12 oz
    The three questions below refer
    of your drinking pattern provided it was aattypical week.
    5% alcohol Liquor highball/
    to your alcohol consumption in cocktail: 50 ml or
    A "unit
    the pastofweek,
    alcohol" (as in indicator
    a useful Question 1 below) is equivalent to any of these: 1.5 oz shot of
    • one regular-sized bottle of beer or cider (350 ml or 12 oz at 5% alcohol)
    of your drinking pattern provided hard liquor at
    40% alcohol
    it was a typical week. A "unit of (50 ml or 1.5 oz shot of
    • one regular highball or cocktail hard liquor at 40% alcohol)
    Cider Small glass
    • one small glass of wine (150isml or 5 oz at 12% alcohol) of wine:
    alcohol" (or "standard drink") 150 ml
    • one smalltoglass
    equivalent of these:
    any of sherry or port (100 ml or 3.5 oz at 18% alcohol) or 5 oz at
    12% alcohol

    Questionnaire
    male  female 

    QUESTIONNAIRE
    1. How many units of alcohol, if any, have you had each day in the last week?
    Record the number you consumed on the timeline below.
    1. How many units of alcohol did you have each day in the last week?
    Record the number you consumed on the timeline below.
    7 days ago 6 days ago 5 days ago 4 days ago 3 days ago 2 days ago yesterday total
    TOTAL
    UNITS:
    2. How
    7 daysmany
    ago times did
    6 days you combine
    ago 5 days ago drinking
    4 days with
    ago one or more
    3 days ago of2 the
    daysfollowing?
    ago yesterday
    • driving or using machinery
    2. During • other situations where alertness is required
    time(s) the last week, how many times did you drink
    • use
    • in situations of depressant
    where substances,
    mental alertness and/orincluding
    physicalmedications
    coordination(e.g., painkillers, sleeping pills, tranquillizers)
    is required
    • pregnancy or breastfeeding
    (e.g., bicycling, driving or using potentially dangerous equipment, work, school,
    3. Howsports,
    many days,
    mindingif any, in the past week did you find it difficult or uncomfortable to stop drinking once you started?
    children)
    In•other words, on how many days
    in certain social situations suchdidasyou experience
    against parentalanxiety or stress
    guidance, at the
    to cope thought of cutting yourself off from
    with
    the next drink?
    being alone or in order to fit in TOTAL
    • while using other drugs (e.g., energy drinks, marijuana, ecstasy, cocaine, or TIMES:
    medications such as antidepressants, pain killers, sleeping pills)
    •day(s)
    when suffering from a serious physical or mental illness
    • while pregnant or breastfeeding
    3. How many times in the past week did you find it difficult or uncomfortable to stop TOTAL
    Interpretation
    drinking once you started? TIMES:
    An on-site clinician will help you interpret your responses and provide you with take-home resource materials.

    INTERPRETATION
    An on-site clinician will help you interpret your responses and provide you with take-home resource materials.

    Staff use:
    Staff  Low risk
    risk pattern  Increased
    pattern  Increasedrisk
    riskpattern High
    pattern  Highrisk
    riskpattern
    pattern

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