Alcoholism Questionnaire

Welcome to our Online Alcoholism Questionnaire — the quickest way to learn about treatment options and procedures at our addiction clinic. Start here to get clear answers and take the first step toward recovery.

Client Satisfaction Survey Form (#6) (#7)

Online Alcoholism Questionnaire

First Name

Country

Date of Birth

Phone Number

What tablets do you use now, at what doses daily, and how?

Was the dose increasing?

What is the longest period you've spent without a tablet?

Have you experienced any of the following: allergies, seizures, fainting, hallucinations, or depression?

Where and how was it previously treated, and what were the results?

Note: