Thank you for partaking in our research questionnaire, we will use the results from these questions to improve how we provide help to you and others who need it.
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What e-mail address did you use to register for Daybreak *

 
Where did you first find out about Daybreak?


 
It is important that we ask some questions about your use of alcohol. Your answers will remain confidential so please be honest.

 
How often do you have a drink containing alcohol? *


 
How many drinks containing alcohol do you have on a typical day when you are drinking? *


 
How often do you have six or more drinks on one occasion ? *


 
How often during the last year have you found that you were not able to stop drinking once you had started? *


 
How often during the last year have you failed to do what was normally expected of you because of drinking? *


 
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session ? *


 
How often during the last year have you had a feeling of guilt or remorse after drinking? *


 
How often during the last year have you been unable to remember what happened the night before because of your drinking? *


 
Have you or someone else been injured because of your drinking? *


 
Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? *


 
The following questions ask about how you have been feeling during the past 30 days. For each question, please select the option that best describes how often you had this feeling.

 
During the past 30 days, about how often did you feel …

 
... tired for no good reason? *


 
... nervous? *


 
... so nervous that nothing could calm you down? *


 
... hopeless? *


 
... restless or fidgety? *


 
... so restless you could not sit still? *


 
... depressed? *


 
... that everything was an effort? *


 
... so sad nothing could cheer you up? *


 
... worthless? *


 
In the last four weeks, how many days were you TOTALLY UNABLE to work, study or manage your day to day activities because of these feelings? *

 
[Aside from those days], in the last 4 weeks, HOW MANY DAYS were you able to work or study or manage your day to day activities, but had to CUT DOWN on what you did because of these feelings? *

 
In the last 4 weeks, how many times have you seen a doctor or any other health professional about these feelings? *

 
In the last 4 weeks, how often have physical health problems been the main cause of these feelings? *


 
In the last 8 weeks, have you consulted with a doctor, therapist, or other healthcare provider? *

     
 
In the last 8 weeks, how many times have you consulted one of the following physicians (doctors):

 
General Practicioner *

 
Psychiatrist *

 
Cardiologist *

 
Ear-Nose-Throat specialist *

 
Gastroenterologist *

 
Dermatologist *

 
Others *

 
In the last 8 weeks, how many times have you consulted one of the following healthcare providers:

 
Psychologist *

 
Nurse *

 
Social Worker *

 
Physiotherapist *

 
Occupational therapist *

 
Alternative Treatment (e.g., homeopathy, acupuncture) *

 
Others *

 
On how many days in the last week did you feel so impaired by your symptoms, that even though you went to school or work, your productivity was reduced? *

 
On how many days in the last week did your symptoms cause you to miss school or work, or leave you unable to carry out your normal daily responsibilities? *

 
During a typical 7-Day period (a week), how many times on average do you do the following kinds of exercise for more than 15 minutes during your free time (write on each line the appropriate number).

 
STRENUOUS EXERCISE (HEART BEATS RAPIDLY) *

(e.g., running, jogging, hockey, football, soccer, squash, basketball, cross country skiing, judo, roller skating, vigorous swimming, vigorous long distance bicycling)
 
MODERATE EXERCISE (NOT EXHAUSTING) *

(e.g., fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, alpine skiing, popular and folk dancing)
 
MILD EXERCISE (MINIMAL EFFORT) *

(e.g., yoga, archery, fishing from river bank, bowling, horseshoes, golf, snow-mobiling, easy walking)
 
During a typical 7-Day period (a week), in your leisure time, how often do you engage in any regular activity long enough to work up a sweat (heart beats rapidly)? *


 
During the past month, how would you rate your sleep quality overall?


 
What is your ethnicity?


 
We are working really hard to bring Daybreak to as many people who need it as possible. To help us in this goal, would you be open to talking to media about your Daybreak experience?


Thank you for the time you've dedicated to this questionnaire, in the coming months we might send this again to track your progress.
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