Age____ Sex____

Circle one:

1.) Do you drink?     Yes             No

2.) Do your parents ...... Know because you have told them?

                                           Know because they’ve caught you?

                                           Not know at all?

3.) If your parents don’t know, is this because you’re afraid you will get in trouble?     Yes                No

4.) If you do Drink, how often do you?       Every day

                                                                           Every weekend

                                                                           3-4 times a week

                                                                           Once or twice a month?

                                                                           Less than once a month?

5.) If you do drink, what do you drink? (Circle all that apply)    Beer              Wine                 Hard Liquor

6.) Do you drink to.......    Get drunk                or                 Have fun

7.) Do you think that you have a drinking problem?               Yes                       No