Annual Behavioral Health Questionnaire
Download Questionnaire PDF
Once a year, we ask all our patients to complete this form on conditions that affect their health. Please help us provide the best medical care by answering the three brief questions below using the following key:
|
Never
0 |
Monthly or less
1 |
2 to 4 times a month
2 |
2 to 3 times a week
3 |
4 or more times a week
4 |
Please CHOOSE the BEST response to each question:
In the past year...
| How often did you have a drink containing alcohol in the past year? |
0 |
1 |
2 |
3 |
4 |
| How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? |
0 |
1 |
2 |
3 |
4 |
| How often did you have 6 or more drinks on one occasion in the past year? |
0 |
1 |
2 |
3 |
4 |