Question

YES

NO

1.

Do you drink or use to overcome shyness or to feel more confident?

2.

Are you having money troubles because of drinking or using?

3.

Do you ever stay home from work because of drinking or using?

4.

Is drinking or using causing trouble in your family?

5.

Is drinking or using giving you a bad reputation?

6.

Have you lost a job or a business because of drinking or using?

7.

Do you drink or use to escape your problems?

8.

Do you drink or use when you are alone?

9.

Do you have blackouts? (Loss of memory for events that happened or of actions you performed while drinking or using?)

10.

Have you missed days of work or school because of your using alcohol or drugs?

11.

Do you feel remorse after drinking or using?

12.

Do you drink in the morning?

13.

Have you ever been in a hospital because of drinking or using?

14.

Has a doctor ever treated you for your drinking or using?

15.

Do you drink or use too much at the wrong time?

16.

Do you make promises to yourself or others about your drinking or using?

17.

Do you have to keep on drinking or using once you have started?

18.

Is drinking or using making it hard for you to sleep?

19.

Have you had an accident because of drinking or using?

20.

Do you drink or use to relieve the painfulness of living?

21.

Do you have trouble disposing of cans or bottles?

22.

Are you less particular about people you are with and the places you go when you are drinking or using?

23.

Have you been arrested more than once for drunk driving or driving under the influence of drugs?

24.

Has drinking or using affected your health?