Questionnaire: Alcoholic Beverage

Topics: Alcoholic beverage, Family, Ethanol Pages: 3 (455 words) Published: November 20, 2013

Questionnaire

I am a 5th form student of the Antigua Girls’ High School . I am carrying out a questionnaire on the problem “How can alcohol affect a teen’s family and social life”. This questionnaire is part of my Social Studies SBA and must be filled out as accurately as possible. Please answer all questions with a () and follow any instructions that are associated. Your co-operation and participation is greatly appreciated.

1. a) Gender
□ Male □ Female

b) Age Range
□ 10-12 yrs □13-15 yrs
□16-18 yrs □19 +

c) What form are you in?
□ 1st □ 2nd □ 3rd □ 4th □ 5th

2. Do you drink alcohol? If no, Please do not continue questionnaire. □ Yes □ No

3. How long have you been drinking alcohol?
□ 0-4 yrs □ 5-9 yrs □ 10 yrs +

4. What is your usual daily consumption of alcohol?
□ 0-3 times □ 4-7 times □ 8-11 times □ 12 times +

5. Is your family aware that you consume alcohol?
□ Yes □ No

6. Are you allowed to consume alcohol?
□ Yes □ No

7. Are you influenced to consume alcohol on a regular basis? If ‘yes’, state by whom. □ Yes □ No
b) ___________________________________________

8. How many persons are in your household?
□ 2-4 persons □ 5-7 persons □ 8 persons +

9. Does everyone in your family consume alcohol? If ‘no’, state whom. □ Yes □ No
b) ___________________________________________

10. Do you drink for special occasions?
□ Yes □ No

b) What special occasions do you mostly consume alcohol? Tick all that apply. □ Birthdays □ Anniversaries □ Graduations □Holidays □Parties

11. Is your family divided by the consumption of alcohol in the home? If ‘yes’, state how. □ Yes □ No
b) ___________________________________________

12. Does...
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