The Sobering Truth
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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:________________________

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A Book by Jeff Herten, M.D.

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