Form 1 Alcohol Use

Public reporting burden for this collection of information is estimated to average 03
minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it displays a currently
valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this
burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Visit 2 Alcohol Use Questionnaire
FORM CODE: ALE
VERSION: 1, 1/6/2014

ID NUMBER:

Contact
Occasion

0

2

SEQ #

ADMINISTRATIVE INFORMATION

/

0a. Completion Date:
Month

/
Day

0b. Staff ID:
Year

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to
code 'Don’t know/refused, Missing, etc.' for those questions that do not list these as an option.

The next questions are about alcoholic beverages. Serving sizes for alcohol use in “standard drink” units
are as follows: Beer = 12oz. glass or 355ml bottle; Wine = 3.5oz glass, 1 bottle =750ml= 8 glasses; Hard
spirits = 1.5oz. or 1 shot.
1. Do you presently drink alcoholic beverages?
No 0
Yes 1

 GO TO QUESTION 7

2. How many glasses of red wine do you usually have per week?
(if less than 1 per week enter “00”)
3. How many glasses of white wine do you usually have per week?
(if less than 1 per week enter “00”)
4. How many cans, bottles, or glasses of beer do you usually have per week? Beer includes more
traditional beverages such as pulque and chicha.
(if less than 1 per week enter “00”)
5. How many drinks of liquor, spirits, or mixed drinks do you usually have per week? Spirits includes
liquor such as whiskey, vodka, tequila, rum, and mixed drinks such as martinis, as well as more
traditional beverages such as aguardiente and cañita. (1 serving = 1.5 oz or 1 shot)
(if less than 1 per week enter “00”)
6. How often did you have 4 or more drinks [for females] and 5 or more drinks [for males] containing any
kind of alcohol within a two-hour period? (Mark only one)
Every day
1
5 to 6 days a week
2
3 to 4 days a week
3
2 days a week
4
1 day a week
5
2 to 3 days a month
6
1 day a month
7
Less than once a month
8
Never
9
 END OF QUESTIONNAIRE
ALE-Alcohol Use-1-6-2014.doc

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FORM CODE: ALE
VERSION: 1, 1/6/2014

ID NUMBER:
7. Did you ever drink alcohol?

No
Yes

0
1

Contact
Occasion

0

2

SEQ #

 END OF QUESTIONNAIRE

8. About how long ago did you stop drinking alcohol? (Mark only one)
Less than 1 year ago 1
1 - 2 years ago
2
More than 2 years ago 3
9. Did you stop drinking alcohol for health reasons?
No
0
Yes
1
10. Did you stop drinking alcohol on the advice of a doctor (or health worker)?
No
0
Yes
1

ALE-Alcohol Use-1-6-2014.doc

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