Chapter 50

Informed Consent for the Consumption of Alcohol


DATE:________________

I, __________________________________, have been thoroughly informed of the risks of drinking alcohol. Specifically, I have been informed of the following (initial each statement):

________Alcohol can be addictive.

________Alcohol is a poison.

________Alcohol can cause aggressive behavior.

________Alcohol can cause temporary insanity.

________Alcohol can lead to unwanted sexual encounters.

________Alcohol can lead to sexually transmitted diseases.

________Alcohol can lead to unplanned pregnancies.

________Alcohol can cause severe depression.

________Alcohol can cause suicide.

________Alcohol can lead to other dangerous addictions such as methamphetamine, cocaine, heroin, and narcotic painkillers.

________Alcohol can get me arrested.

________Alcohol may promote dishonesty and immorality.

________I understand that alcohol is a factor in 50 percent of fatal highway accidents.

________I understand that alcohol is a factor in 50 percent of all homicides.

________I understand that alcohol is a factor in 50 percent of all spousal and child abuse.

________Alcohol can cause cancer of the mouth, throat, esophagus, stomach, colon, pancreas, liver, and prostate.

________If I already have had cancer, alcohol can allow it to spread throughout my body.

________Alcohol can cause osteoporosis (weakening of my bones).

________Alcohol can make my allergies worse.

________Alcohol can cause insomnia (sleeplessness).

________Alcohol can cause severe heartburn or gastroesophageal reflux disease (GERD).

________Alcohol can weaken my immune system.

________Alcohol can cause hepatitis, progressing to cirrhosis.

________Alcohol can cause pancreatitis.

________Alcohol can weaken my heart.

________Alcohol can cause obesity.

________Alcohol can cause diabetes.

________Alcohol can cause hypoglycemia (low blood sugar).

________Alcohol can cause memory loss and dementia.

________Alcohol can cause neuropathy (a painful burning of the hands and feet).

WOMEN ONLY:

________Even small amounts of alcohol can cause birth defects.

________Alcohol can increase my risk of breast cancer six times the national average.

I certify that I am of sound mind and body and have made the decision to drink alcohol, having understood all the possible consequences and considered the risks. I make this decision of my own accord and will hold no one else responsible. I am not giving in to peer pressure from my friends just because I want to be accepted as one of the group. I hold harmless the manufacturers and marketers of alcohol as I feel I have been adequately informed of the physical and psychological risks of drinking alcohol.

Signed:_____________________

Date:_______________