Chapter 46
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 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).
________ Even small amounts of alcohol can cause birth defects.
________ Alcohol can increase my risk of breast cancer six times the national average (women only)
________ Alcohol can cause aggressive behavior.
________ 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.
________ I understand that alcohol can get me arrested.
________ I understand that alcohol is a factor in 32% of fatal highway accidents.
________ I understand that alcohol is a factor in 48% of all homicides.
________ I understand that alcohol is a factor in 55% of all spousal abuse.
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:________________________
