Hangover Severity and Symptom Tracker
These are the intoxication questionnaire notes for "When in a Dark Place."
Below is a typical example of an intoxication questionnaire used in Terramagne-American sobering centers and other substance care facilities. These often have multiple blank lines to fill in further symptoms, treatments, etc. An online version offers a checklist for each section, and then presents a set of labeled scales for all the checked items. It can automatically calculate the average and suggest an overall severity, but the user can modify that by dragging the slider.
Hangover Severity and Symptom Tracker
Date: __________ Time: __________
How many standard drinks did you have? __________
How long was your drinking session? __________
What type(s) of alcohol did you drink? _________________________________
What type(s) of nonalcoholic beverages did you have during your drinking session or before you went to bed? ___________________________________
What type(s) of food did you eat during your drinking session or before you went to bed? _________________________________________________________
Have you slept since you stopped drinking? (Yes) (No)
If you slept, how much rest did you get? __________
Quality of Sleep
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Slept like a baby ... Okay ... Meh ... Poor ... No Sleep
Alertness After Sleep
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Wide Awake ... Okay ... Meh ... Still Sleepy ... Zombie
Physical Symptoms
Rate the effects of this drinking session on your body.
Fatigue
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Alert ........ Awake ... Meh .... Tired .... Dead on Feet
Nausea / Vomiting
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ..... Meh ... Queasy ... Vomited 1 ... Vomited 2+
Clumsiness
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Butterfingers ... Bull in China Shop
Dizziness
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Spinning ... Clutching the Floor
Balance Problems
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Steady ... Unsteady ... Tilting ... Can't Stay Straight ... Can't Move
Aches and Pains
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Ouch ... Miserable ... Hit by Truck
Other
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Awful ... Devastating
Overall Physical
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Awful ... Devastating
Body Map
Use color and shapes to draw your symptoms on this body map. Include a key labeling your symbolism.
Mental Symptoms
Rate the effects of this drinking session on your mind.
Agitation / Restlessness
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Calm ... Okay ... Meh ... Twitchy ... Vibrating in Place
Memory Problems
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Elephant ... Minor ... Some ... Where Am I? ... Who Am I?
Confusion
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Focused ... Unfocused ... Fuzzy ... Baffled ... WTF??
Regret / Guilt
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... I'm Bad ... OMG What Have I Done?
Impulsivity
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Controlled ... Mindful ... Meh ... Careless ... Reckless ... No Brakes
Depression
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Happy ... Okay ... Meh ... Unhappy ... Blue ... Dark Night of the Soul
Other
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Awful ... Devastating
Overall Mental
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Awful ... Devastating
Overall Severity
Rate the total impact of your condition.
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Good ... Okay ... Meh ... Miserable ... Death Warmed Over
Treatments
List the things you have done to relieve your symptoms. Rate their effectiveness from 1 (useless) to 10 (excellent).
Water (number of glasses): __________ Effectiveness: ( )
Other Nonalcoholic Beverages: _____________________ Effectiveness: ( )
Foods: _________________________________________ Effectiveness: ( )
Supplements: ___________________________________ Effectiveness: ( )
Other Home Remedies: ___________________________ Effectiveness: ( )
Over the Counter Medications: ______________________ Effectiveness: ( )
Prescription Medications: ___________________________ Effectiveness: ( )
Other Medical Care: ______________________________ Effectiveness: ( )
Friend or Other Caregiver: _________________________ Effectiveness: ( )
Worth Repeating: _________________________________________________
Not Worth Repeating: ______________________________________________
Notes: _________________________________________________________
Risk and Resilience Factors
Is anything besides alcohol interfering with your ability to function?
( ) Yes: ______________________________________________________
( ) No
Challenges take work to move through, especially when complicated by alcohol. Try to remove obstacles, practice self-compassion, and take care of yourself so that you can troubleshoot effectively, then eventually move on with your life.
Who is supporting you in this difficult time? Check all that apply.
( ) Immediate family: ______________________________________________
( ) Close friends: _________________________________________________
( ) Extended family: _______________________________________________
( ) Neighbors and community: _______________________________________
( ) Online contacts: _______________________________________________
( ) Casual friends and coworkers: ____________________________________
( ) Support group or other social club: _________________________________
( ) Clergy or other religious help: _____________________________________
( ) Counselor or other mental worker: _________________________________
( ) Sobriety center or similar facility: __________________________________
( ) Sober companion: _____________________________________________
( ) Other: _______________________________________________________
( ) Nobody seems to care
Problem drinking is always hard to handle, but social support can facilitate the process and reduce the chance of complications. The more and better support you have, the better your outcomes. Ask for help if you need more than you are getting. We are here for you.
What protective factors do you have against problem drinking? Check all that apply.
( ) Good housing in a decent neighborhood
( ) A fulfilling job that you enjoy and pays well
( ) Friends, neighbors, and coworkers you like
( ) A functional family life (birth, married, and/or choice)
( ) High educational achievement and/or social expectations
( ) Good physical and emotional health
( ) Accessible and effective health care
( ) Accessible and effective social services
( ) No trauma, or processed trauma that isn't bothersome
( ) A sense of accomplishment in professional, hobby, or other skills
Protective factors make you more resilient to stress, thus less likely to try solving your problems with alcohol. Look for ways to increase the quantity and quality of protective factors in your life, as a way of raising your resilience.
What risk factors do you have for problem drinking? Check all that apply.
( ) Adverse childhood experiences
( ) Early onset of alcohol use
( ) Trauma experienced as an adult
( ) Genetic variations correlating with addiction issues
( ) A relative with alcoholism, problem drinking, or other substance issues
( ) Negative, ambivalent, or complicated relationships with people
( ) Attachment damage or lack of community connections
( ) Peer pressure or high-alcohol contexts
( ) High-stress work or other environmental aspects
( ) Poverty, homelessness, or other resource lacks
( ) Low educational achievment and/or social expectations
( ) Shortage of alternative coping methods
( ) Depression, anxiety, developmental disability, or other mental issues that could impair your ability to function in a healthy manner
( ) Physical illness, injury, or other bodily issues that could impair your ability to function in a healthy manner
( ) Other: _______________________________________________________
Even one factor can lead to problem drinking, or it can occur unexpectedly. The more risk factors, the more likely it is to develop. If you have three or more of these, seriously consider getting a mental health checkup in 2-4 weeks.
Impressions
What is your typical level of alcohol consumption? _______________________
Was this drinking session below, the same, or higher? ____________________
Why did you choose to drink this time? ________________________________
How well are you coping today?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Effectively ... Sort Of ... Poorly ... Not At All
Has this experience made you think about your drinking habits?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
No Yes, but I'm okay Yes, I'm uneasy Yes, I have a problem
How would you rate your fluency in alcohol issues?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Fluent Adequate Iffy Totally Lost
How would you rate your care at this facility?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Saved My Life ... Helped a Lot ... Meh ... Unhelpful ... Made It Worse
How would you rate the overall quality of support you are receiving?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Compassionate Perfunctory Poor Worse Than Useless
How do you feel after completing this questionnaire?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Better The Same Worse
Is there anything else you would like to share? ___________________________
________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________
Aftercare
Thank you for answering our questions. We wish you healing in this difficult time. If you need more support or information, we can help you find some in a venue convenient for you.
Would you like to hear more about alcohol safety or sobriety resources?
( ) Yes, please.
( ) No, thank you.
Would you like to hear more about coping skills and other resilience factors?
( ) Yes, please.
( ) No, thank you.
Would you like to discuss your alcohol aftercare plans?
( ) Yes, please.
( ) No, thank you.
May we contact you in a few days to see how you are doing?
( ) Yes, please.
( ) No, thank you.
Name:
Phone number:
Email or other electronic address:
Mailing address:
You do not need to give the complete mailing address if you don't want to, but knowing your city and state would help us to recommend resources in your area.
Below is a typical example of an intoxication questionnaire used in Terramagne-American sobering centers and other substance care facilities. These often have multiple blank lines to fill in further symptoms, treatments, etc. An online version offers a checklist for each section, and then presents a set of labeled scales for all the checked items. It can automatically calculate the average and suggest an overall severity, but the user can modify that by dragging the slider.
Hangover Severity and Symptom Tracker
Date: __________ Time: __________
How many standard drinks did you have? __________
How long was your drinking session? __________
What type(s) of alcohol did you drink? _________________________________
What type(s) of nonalcoholic beverages did you have during your drinking session or before you went to bed? ___________________________________
What type(s) of food did you eat during your drinking session or before you went to bed? _________________________________________________________
Have you slept since you stopped drinking? (Yes) (No)
If you slept, how much rest did you get? __________
Quality of Sleep
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Slept like a baby ... Okay ... Meh ... Poor ... No Sleep
Alertness After Sleep
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Wide Awake ... Okay ... Meh ... Still Sleepy ... Zombie
Physical Symptoms
Rate the effects of this drinking session on your body.
Fatigue
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Alert ........ Awake ... Meh .... Tired .... Dead on Feet
Nausea / Vomiting
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ..... Meh ... Queasy ... Vomited 1 ... Vomited 2+
Clumsiness
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Butterfingers ... Bull in China Shop
Dizziness
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Spinning ... Clutching the Floor
Balance Problems
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Steady ... Unsteady ... Tilting ... Can't Stay Straight ... Can't Move
Aches and Pains
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Ouch ... Miserable ... Hit by Truck
Other
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Awful ... Devastating
Overall Physical
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Awful ... Devastating
Body Map
Use color and shapes to draw your symptoms on this body map. Include a key labeling your symbolism.
Mental Symptoms
Rate the effects of this drinking session on your mind.
Agitation / Restlessness
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Calm ... Okay ... Meh ... Twitchy ... Vibrating in Place
Memory Problems
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Elephant ... Minor ... Some ... Where Am I? ... Who Am I?
Confusion
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Focused ... Unfocused ... Fuzzy ... Baffled ... WTF??
Regret / Guilt
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... I'm Bad ... OMG What Have I Done?
Impulsivity
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Controlled ... Mindful ... Meh ... Careless ... Reckless ... No Brakes
Depression
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Happy ... Okay ... Meh ... Unhappy ... Blue ... Dark Night of the Soul
Other
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Awful ... Devastating
Overall Mental
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
None ... Minor ... Some ... Awful ... Devastating
Overall Severity
Rate the total impact of your condition.
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Good ... Okay ... Meh ... Miserable ... Death Warmed Over
Treatments
List the things you have done to relieve your symptoms. Rate their effectiveness from 1 (useless) to 10 (excellent).
Water (number of glasses): __________ Effectiveness: ( )
Other Nonalcoholic Beverages: _____________________ Effectiveness: ( )
Foods: _________________________________________ Effectiveness: ( )
Supplements: ___________________________________ Effectiveness: ( )
Other Home Remedies: ___________________________ Effectiveness: ( )
Over the Counter Medications: ______________________ Effectiveness: ( )
Prescription Medications: ___________________________ Effectiveness: ( )
Other Medical Care: ______________________________ Effectiveness: ( )
Friend or Other Caregiver: _________________________ Effectiveness: ( )
Worth Repeating: _________________________________________________
Not Worth Repeating: ______________________________________________
Notes: _________________________________________________________
Risk and Resilience Factors
Is anything besides alcohol interfering with your ability to function?
( ) Yes: ______________________________________________________
( ) No
Challenges take work to move through, especially when complicated by alcohol. Try to remove obstacles, practice self-compassion, and take care of yourself so that you can troubleshoot effectively, then eventually move on with your life.
Who is supporting you in this difficult time? Check all that apply.
( ) Immediate family: ______________________________________________
( ) Close friends: _________________________________________________
( ) Extended family: _______________________________________________
( ) Neighbors and community: _______________________________________
( ) Online contacts: _______________________________________________
( ) Casual friends and coworkers: ____________________________________
( ) Support group or other social club: _________________________________
( ) Clergy or other religious help: _____________________________________
( ) Counselor or other mental worker: _________________________________
( ) Sobriety center or similar facility: __________________________________
( ) Sober companion: _____________________________________________
( ) Other: _______________________________________________________
( ) Nobody seems to care
Problem drinking is always hard to handle, but social support can facilitate the process and reduce the chance of complications. The more and better support you have, the better your outcomes. Ask for help if you need more than you are getting. We are here for you.
What protective factors do you have against problem drinking? Check all that apply.
( ) Good housing in a decent neighborhood
( ) A fulfilling job that you enjoy and pays well
( ) Friends, neighbors, and coworkers you like
( ) A functional family life (birth, married, and/or choice)
( ) High educational achievement and/or social expectations
( ) Good physical and emotional health
( ) Accessible and effective health care
( ) Accessible and effective social services
( ) No trauma, or processed trauma that isn't bothersome
( ) A sense of accomplishment in professional, hobby, or other skills
Protective factors make you more resilient to stress, thus less likely to try solving your problems with alcohol. Look for ways to increase the quantity and quality of protective factors in your life, as a way of raising your resilience.
What risk factors do you have for problem drinking? Check all that apply.
( ) Adverse childhood experiences
( ) Early onset of alcohol use
( ) Trauma experienced as an adult
( ) Genetic variations correlating with addiction issues
( ) A relative with alcoholism, problem drinking, or other substance issues
( ) Negative, ambivalent, or complicated relationships with people
( ) Attachment damage or lack of community connections
( ) Peer pressure or high-alcohol contexts
( ) High-stress work or other environmental aspects
( ) Poverty, homelessness, or other resource lacks
( ) Low educational achievment and/or social expectations
( ) Shortage of alternative coping methods
( ) Depression, anxiety, developmental disability, or other mental issues that could impair your ability to function in a healthy manner
( ) Physical illness, injury, or other bodily issues that could impair your ability to function in a healthy manner
( ) Other: _______________________________________________________
Even one factor can lead to problem drinking, or it can occur unexpectedly. The more risk factors, the more likely it is to develop. If you have three or more of these, seriously consider getting a mental health checkup in 2-4 weeks.
Impressions
What is your typical level of alcohol consumption? _______________________
Was this drinking session below, the same, or higher? ____________________
Why did you choose to drink this time? ________________________________
How well are you coping today?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Effectively ... Sort Of ... Poorly ... Not At All
Has this experience made you think about your drinking habits?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
No Yes, but I'm okay Yes, I'm uneasy Yes, I have a problem
How would you rate your fluency in alcohol issues?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Fluent Adequate Iffy Totally Lost
How would you rate your care at this facility?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Saved My Life ... Helped a Lot ... Meh ... Unhelpful ... Made It Worse
How would you rate the overall quality of support you are receiving?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Compassionate Perfunctory Poor Worse Than Useless
How do you feel after completing this questionnaire?
1 ... 2 ... 3 ... 4 ... 5 ... 6 ... 7 ... 8 ... 9 ... 10
Better The Same Worse
Is there anything else you would like to share? ___________________________
________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________
Aftercare
Thank you for answering our questions. We wish you healing in this difficult time. If you need more support or information, we can help you find some in a venue convenient for you.
Would you like to hear more about alcohol safety or sobriety resources?
( ) Yes, please.
( ) No, thank you.
Would you like to hear more about coping skills and other resilience factors?
( ) Yes, please.
( ) No, thank you.
Would you like to discuss your alcohol aftercare plans?
( ) Yes, please.
( ) No, thank you.
May we contact you in a few days to see how you are doing?
( ) Yes, please.
( ) No, thank you.
Name:
Phone number:
Email or other electronic address:
Mailing address:
You do not need to give the complete mailing address if you don't want to, but knowing your city and state would help us to recommend resources in your area.