Name *

First Name

Last Name

1. Do you lose time from work due to drinking or drug use? *

True

False

2. Is drinking or drug use making your home life unhappy? *

True

False

3. Do you drink or use drugs because you are shy with other people? *

True

False

4. Is drinking or drug use affecting your reputation? *

True

False

5. Have you ever felt remorse after drinking or drug use? *

True

False

6. Have you gotten into financial difficulties as a result of your drinking or drug use? *

True

False

7. Do you turn to lower companions and an inferior environment when drinking or using drugs? *

True

False

8. Does your drinking or drug use make you careless of your family’s welfare? *

True

False

9. Has your ambition decreased since drinking or using drugs? *

True

False

10. Do you crave a drink or a drug at a definite time daily? *

True

False

11. Do you want a drink or drug the next morning? *

True

False

12. Does your drinking or drug use cause you to have difficulties in sleeping? *

True

False

13. Has your efficiency decreased since drinking or using drugs? *

True

False

14. Is your drinking or drug use jeopardizing your job or business? *

True

False

15. Do you drink or use drugs to escape from worries or troubles? *

True

False

16. Do you drink or use drugs alone? *

True

False

17. Have you ever had a complete loss of memory? *

True

False

18. Has your physician ever treated you for drinking or drug use? *

True

False

19. Do you drink or use drugs to build your self-confidence? *

True

False

20. Have you ever been in a hospital or institution on account of drinking or drug use? *

True

False