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Have you ever quit drinking before?
No
Yes, 1 week
Yes, 1 month
Yes, 6 months
Yes, 1+ years
How long have you been drinking for?
1 Year
1-5 Years
5-10 Years
10-20 Years
20+ Years
Have you used any quit drinking aides?
Yes
No
How often do you drink?
Once or Twice a Week
Every other day
Everyday
Have you ever been emotionally effected by a movie, story, etc?
Almost Always
Most of the time
Sometimes
Not Often
Rarely
Never
Name
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a before? Email
Email
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