Name(Optional): _____________________________ Gender: ____________

DIRECTIONS: Please read and understand the following questions and choose the items that

would best answer the questions. Put a check mark (/) in the given space before each item.

1. Do you drink alcoholic beverages?

__ Yes, I drink

__ Yes, but I quit now

__ No, I don’t drink

2. At what age did you start consuming/drinking alcohol?

__ 11-12 Years Old

__ 13-14 Years Old

__ 15-16 Years Old

__ 17-18 Years Old

__ 18 years old and above

3. How often do you drink alcohol?

__ everyday

__ 3-5 times a week

__ once a week

__ only on weekend

__ on special occasion

Others please specify__________________________

4. How many drinks containing alcohol do you have on a typical day when you are

drinking?

__ 1-3 bottles

__ 4-6 bottles

__ 7-9 bottles
 __ 10 bottles and above

5. What kind of alcohol have you tried? (You may check more than one)

__ Beer

__ Wine

__ Gin

__ Rum

__ Tequila

Others please specify________________

6. What are your reasons and factors that influences you in starting and engaging in

alcohol drinking?

__ peer influence

__ peer influence

__ curiosity

__ because you ‘felt like it’ (bored)

__ influence of an adult

__ to enhance sociability

__ to escape problem

__ for enjoyment

Others please specify_____________________

7. Have you ever skipped or missed a class because of drinking?

__ Yes

__ No

8. What level of knowledge do you have about alcohol drinking?

__ poor knowledge

__ moderate knowledge
 __ good knowledge

__ excellent knowledge

9. How dangerous of a risk is alcohol, in your opinion, to you overall health and

achievement of life goals?

__ No Risk

__ Slight Risk

__ Moderate Risk

__ Great Risk

10. Have you been injured as a result of drinking?

__ Yes

__ No

11. Have you ever become violent or aggravated while drinking?

__ Yes

__ No

12. What percentage of students your age here in your barangay do you believe drank 5 or

more drinks in a row at least once within the past 30 days?

__ 0%

__ 20%

__ 40%

__ 60%

__ 80%

__ 100%

13. Which statements below about drinking alcoholic beverages do you feel best

represents you own attitude?

__ Drinking alcohol is never a good thing to do

 __ Drinking is all right but you should never get drunk

__ Occasionally getting drunk is okay as long as it doesn’t interfere with academics or

other responsibilities

__ Occasionally getting drunk is okay as long as it does interfere with academics or

other responsibilities

__ Frequently getting drunk is okay if that’s what the individual wants to do

Others please specify__________________

14. Which statements below about drinking alcoholic beverages do you feel best

represents the most common attitude among students in general here?

__ Drinking alcohol is never a good thing to do

__ Drinking is all right but you should never get drunk

__ Occasionally getting drunk is okay as long as it doesn’t interfere with academics or

other responsibilities

__ Occasionally getting drunk is okay as long as it does interfere with academics or

other responsibilities

__ Frequently getting drunk is okay if that’s what the individual wants to do

Others please specify__________________