Name
*
First Name
Last Name
Email
*
Have you ever experienced Asian Flush or physical discomfort (redness, nausea, rapid heartbeat) after drinking?
*
Yes, every time I drink
Sometimes
No, never
Do you ever feel pressured to drink at social or family gatherings, even when you don’t want to?
*
Often
Occasionally
Never
Have you ever drank more than you intended, even when you planned to stop at a certain amount?
*
Frequently
Sometimes
Rarely or never
Have you ever used alcohol to cope with stress, anxiety, or feeling out of place in social settings?
*
Yes, often
Sometimes
No, not really
Have you ever felt guilty or regretful about drinking?
*
Frequently
Occasionally
Never
Do you avoid talking about drinking habits because of stigma or cultural expectations in your family or community?
*
Yes, all the time
Occasionally
No, I feel comfortable discussing it
Have you ever thought about cutting back or stopping drinking but didn’t know where to start?
*
Yes, but I don’t know what to do
I’ve considered it but haven’t taken action
No, I’ve never thought about it
Mostly “Yes” or “Frequently” Answers: judgment-free space to explore your relationship with alcohol.
A Mix of Answers:
Mostly “No” or “Never” Answers:
