Att G_Activity Worksheet: Excessive Drinking Problems

Attachment G: Activity Worksheet Excessive Drinking Problems

Form Approved

OMB No. 0920-xxxx

Expiration date: xx/xx/xxxx

PROBLEMS ASSOCIATED WITH EXCESSIVE DRINKING

INSTRUCTIONS:

Highlight in GREEN below what you believe are the most important problems related to excessive drinking in your community. Please don’t highlight items you don’t think are important problems related to excessive drinking in your community. If there is an important problem that you don’t see listed, please use the “Other” line to write it in and highlight.

________	Chronic Diseases High blood pressure, heart disease, stroke, liver disease, breast cancer	________	Economic Costs Lost productivity, unemployment, healthcare costs, criminal justice costs
________	Injuries Motor vehicle crashes, falls, drownings, poisoning	________	Mental Health and Addiction Alcohol dependence/alcoholism, other drug problems, anxiety, depression
________	Violence Homicide, suicide, intimate partner violence, sexual assault	________	Learning or Memory Problems Dementia, poor school performance
________	Reproductive Health Unintended pregnancy, sexually-transmitted diseases, HIV	________	Problems with Relationships Separation, divorce, divided families, social isolation
________	Problems During and After Pregnancy Miscarriage, stillbirth, fetal alcohol spectrum disorders, sudden infant death syndrome	________	Quality of Life Noise around drinking establishments, property damage, traffic congestion
________	Poor Nutrition Excess calories, weight gain	________	OTHER: _______________________________
________	OTHER: _______________________________	________	OTHER: _______________________________