About My Drinking Screening Tool

The 18 question screening tool is anonymous and has been designed to help you, your loved ones or your health care professional answer some questions about drinking. When you have finished the test you can print or email your Final Report directly to yourself or your health care professional.

Please begin the survey by filling in the following anonymous information. Assuring security and confidentiality are hallmarks of Hazelden. Hazelden does not provide or release names or email addresses to any third party. Please see the Privacy Policy in the site footer for details.

Your first name:  (to protect your privacy please only use your first name or a nickname)

You are:

malefemale

Your date of birth:  Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year After 1997 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912

Your email address is:       
After you sign up we’ll send you your registration information.

I prefer to not submit an email address. I understand that this means that I will not be able to use the site to help me auto-retrieve a lost password.


The password you would like to use is:     
Password note: To protect your privacy, please choose a secure password that contains at least 8 characters of both letters and numbers.

How much do you weigh?

------ lbs. kgs.

You are taking this test:
For yourself
For someone you know
You are just checking out the screening tool to see what the results look like

How much would you say that each drink costs you?

$

(example: 3.75)

Please Note: By clicking "Start the Screening" you acknowledge that this screening is for educational puposes only and is not to be used as a substitute for a consultation or visit with your family physician or other healthcare provider.

Statistical data collected throughout the site is used for research purposes only. Individual statistics are not collected or distributed and we do not collect or distribute email addresses or any other personal information. Please read this important legal information.

Please check this box to acknowledge that your non-personal information will be used for purposes of improving this program. Your use of this program is subject to your data being used for research puposes. We do not collect or analyze individual statistics and no one will contact you at any time.