The Alcohol Use Assessment Form Template by WPForms is a great tool for support groups, counselors, and healthcare providers who want to simplify the process of assisting those struggling with alcohol addiction.
How Does the Alcohol Use Assessment Form Template Work?
The Alcohol Use Assessment Form Template requires the WPForms Pro License and the Survey and Polls Addon to work efficiently and gather results from applicants in visual charts and graphs. Fields include:
- Personal Information:
- Name: Records the individual’s full name for a personalized assessment.
- Date of Birth: Helps verify the age and is crucial for age-related analysis.
- Phone: A direct line for timely communication and follow-ups.
- Email: Essential for sending assessment results and educational materials.
- Alcohol Use History:
- Age at First Drink: Offers insight into the onset of alcohol use.
- Frequency of Alcohol Use: Identifies how often the individual consumes alcohol.
- Typical Quantity Consumed: Sheds light on average consumption patterns.
- Maximum Quantity in 24 Hours: Highlights instances of heavy drinking.
- Impact of Alcohol Use:
- Physical Health Effects: Investigates any physical repercussions of alcohol use.
- Mental Health Effects: Explores the psychological impact, if any.
- Impact on Work: Assesses how alcohol consumption affects professional life.
- Impact on Relationships: Examines the effect on personal relationships.
- Readiness to Change:
- Interest in Reducing Drinking: Gauges motivation for change.
- Previous Attempts to Cut Down: A history of efforts to reduce alcohol use.
- Support System: Identifies the presence of a supportive environment.
- Additional Comments: Space for any other relevant information or concerns.
Sign up with WPForms today and access the Alcohol Use Assessment Form Template, which is designed for organizations, health professionals, and support groups aiming to facilitate discussions about alcohol use and its effects.
