1. Do you feel you are a normal drinker/user? By normal we mean you q YES q NO
drink/use as much or less than most other people.
2. Have you ever awaken the morning after some drinking/drugging the q YES q NO
night before and found that you could not remember a part of the
evening before?
3. Does your spouse, parents, or other near relatives ever worry or q YES q NO
complain about your drinking/drugging/pill usage?
4. Can you stop drinking/using without a struggle after one or two? q YES q NO
5. Do you feel guilty about your drinking/chemical dependency? q YES q NO
6. Do friends or relatives think you are a normal drinker/user? q YES q NO
7. Do you ever try to limit your drinking/using to certain times of the q YES q NO
day or to certain places?
8. Are you always able to stop drinking/drugging/pills, etc. when you q YES q NO
want to?
9. Have you ever attended a meeting of Alcoholics Anonymous (AA)? q YES q NO
10. Have you gotten into a verbal or physical fight when drinking/using? q YES q NO
11. Has drinking/using/drugs ever created problems between you and your q YES q NO
wife, husband, a parent or other near relatives?
12. Has you wife, husband, (or other family members) ever gone to anyone q YES q NO
for help about your drinking/drug use?
13. Have you ever lost friends or girlfriends because of your drinking/drugs? q YES q NO
14. Have you ever gotten into trouble at work because of drinking/drugs? q YES q NO
15. Have you ever lost a job or quit before you were fired because of q YES q NO
drinking/using drugs?
16. Have you ever neglected your obligations, your family or your work q YES q NO
for 2 or more days in a row because you were drinking/using?
17. Do you drink/use drugs or pills before
weekends)?
18. Have you ever been told you have liver trouble? q YES q NO
19. Have you ever had a delirium treatment (D.T.’s), severe shaking, heard q YES q NO
voices, or seen things that weren’t there after heavy drinking/using?
20. Have you ever gone to anyone for help about drinking/using? q YES q NO
21. Have you ever been in a hospital because of drinking/drug use? q YES q NO
22. Have you ever been a patient in a psychiatric hospital or in a psychiatric q YES q NO
ward of a general hospital where drinking/drugs were part of the problem?
23. Have you ever been seen at a psychiatric or mental health clinic or gone to q YES q NO
a doctor, social worker, or clergyman for help with an emotional problem
in which drinking/drugs had played a part?
24. Have you ever been arrested, even for a few hours, because of drinking/ q YES q NO
drug behavior? (If YES, how many times?_________)
25. Have you ever been arrested for drunk driving, driving while intoxicated q YES q NO
or driving under the influence of alcoholic beverage or drugs? (If YES,
how many times)?