| 1. Do you often use drugs or drink alcohol alone? |
YES |
NO |
| 2. Have you tried to cut down on your drinking or drug use? |
YES |
NO |
| 3. Are you bothered when others ask you about your drinking or drug use? |
YES |
NO |
| 4. Has your alcohol use ever created problems between you and your family? |
YES |
NO |
| 5. Have you felt guilty about your drinking or drug use? |
YES |
NO |
| 6. Does your drinking or drug use often make it difficult to sleep through the night? |
YES |
NO |
| 7. Do you drink or use drugs to decrease tension or worries? |
YES |
NO |
| 8. Are friends or relatives concerned about your drinking or drug use? |
YES |
NO |
| 9. After one or two drinks, do you find it hard to stop drinking? |
YES |
NO |
| 10. Have you ever worried because you may not have alcohol or drugs when you need them? |
YES |
NO |
| 11. Do you crave a drink or drug at a certain time every day? |
YES |
NO |
| 12. Have you ever lost time or gotten into trouble at work because of drinking or drug use? |
YES |
NO |
| 13. When you are around alcohol or drugs and not drinking or using, do you feel shaky, nervous or jumpy? |
YES |
NO |
| 14. Do you use alcohol or drugs to build your self-esteem? |
YES |
NO |
| 15. Have you ever been arrested for driving under the influence of alcohol or drugs? |
YES |
NO |
| 16. Have your efficiency and ambition decreased following drinking or drug use? |
YES |
NO |
| 17. Is drinking or using drugs making your home life unhappy? |
YES |
NO |
| 18. Do you ever want a drink or drug the next morning? |
YES |
NO |
| 19. Has your physician ever treated you for drinking or drug use? |
YES |
NO |
| 20. Have you gotten into financial trouble because of alcohol or drug use? |
YES |
NO |