1. Do you feel you are a normal drinker? ("normal" - drink as
much or less than most other people)
YES or NO
2. Have you ever awakened the morning after some drinking the
night before and found that you could not remember a part of
the evening?
YES or NO
3. Does any near relative or close friend ever worry or
complain about your drinking?
YES or NO
4. Can you stop drinking without difficulty after one or two
drinks?
YES or NO
5. Do you ever feel guilty about your drinking?
YES or NO
6. Have you ever attended a meeting of Alcoholics Anonymous
(AA)?
YES or NO
7. Have you ever gotten into physical fights when drinking?
YES or NO
8. Has drinking ever created problems between you and a near
relative or close friend?
YES or NO
9. Has any family member or close friend gone to anyone for
help about your drinking?
YES or NO
10. Have you ever lost friends because of your drinking?
YES or NO
11. Have you ever gotten into trouble at work because of
drinking?
YES or NO
12. Have you ever lost a job because of drinking?
YES or NO
13. Have you ever neglected your obligations, your family, or
your work for two or more days in a row because you were
drinking?
YES or NO
14. Do you drink before noon fairly often?
YES or NO
15. Have you ever been told you have liver trouble such as
cirrhosis?
YES or NO
16. After heavy drinking have you ever had delirium tremens (D.T.'s),
severe shaking, visual or auditory (hearing) hallucinations?
YES or NO
17. Have you ever gone to anyone for help about your drinking?
YES or NO
18. Have you ever been hospitalized because of drinking?
YES or NO
19. Has your drinking ever resulted in your being hospitalized
in a psychiatric ward?
YES or NO
20. Have you ever gone to any doctor, social worker, clergyman
or mental health clinic for help with any emotional problem in
which drinking was part of the problem?
YES or NO
21. Have you been arrested more than once for driving under
the influence of alcohol?
YES or NO
22. Have you ever been arrested, even for a few hours because
of other behavior while drinking?
(If Yes, how many times ________ )
YES or NO |
