Yes
No
1
Are my peers, friends, or family alleging that my drinking/drug
use is interfering with my work?
2
Do I plan my day around my drinking/drug use?
3
Do I ever feel I need a drink/drug to face certain
situations?
4
Do I frequently drink/use drugs alone?
5
Have I ever had a loss of memory when apparently functioning
because of my drinking/drug use?
6
Do I ever drink/drug before a meeting or court appearance
to calm my nerves, gain courage, or improve my performance?
7
Do I want, or take, a drink/drug the morning after
a hard night drinking/drugging?
8
Have I missed deadlines or appointments because of
my drinking/drug use or because of a hangover?
9
After drinking/drug use, have I ever felt any of the
following: fear, remorse, guilt, loneliness, depression, severe anxiety,
terror, or a feeling of impending doom?
10
Is my drinking/drug use making me careless about my
finances, health or other responsibilities?
11
While drinking/drugging, have I ended up in places
I would not normally frequent or with people I would not normally
socialize with?
12
Do I need or desire a drink/drug to steady my nerves
at a particular time of day or week?
13
Have I ever lied, cheated or stolen to support or cover
up my drinking/drug use?
14
Have I ever tried unsuccessfully to quit drinking/drugging
for any length of time?
15
Have I made attempts to control my drinking/drug use
by limiting it to special occasions, special times of the day, or
certain days of the week, certain number or types of drinks/drugs?
16
Do I avoid people in order to hide the effects of my
drinking/drug use?
17
Have I ever been hospitalized or treated by a doctor
directly or indirectly as a result of my drinking?
18
Is there anyone in any generation of my family who
has been diagnosed, treated for, or sought help for an alcohol, drug
or other addiction problem such as gambling?
