Q: Do you lose time from work due to drinking or drugging?   Y / N

 

Q: Is drinking, drugging, binging or purging making your home life unhappy?   Y / N

 

Q: Do you drink or drug because you are shy with other people?  Y / N

 

Q: Is drinking or drugging affecting your reputation?   Y / N

 

Q: Have you ever felt remorse after drinking or drugging?   Y / N

 

Q: Have you had financial difficulties as a result of  your  drinking or drugging?   Y / N

 

Q: Do you turn to inferior companions and environments when indulging?   Y / N

 

Q: Does your drinking or drugging ever made you careless of your family's welfare?   Y / N

 

Q: Has your ambition decreased since you started drinking or drugging etc?   Y / N

 

Q: Do you crave a drink or a drug at a definite time daily?   Y / N

 

Q: Do you drink or use the next morning?   Y / N

 

Q: Does drinking or drugging cause you to have difficulty in sleeping?   Y / N

 

Q: Has your efficiency decreased since you started drinking or drugging?   Y / N

 

Q: Is your drinking or drugging jeopardizing your job or business?   Y / N

 

Q: Do you drink or use to escape from worries or trouble?   Y / N

 

Q: Do you drink or use alone?   Y / N

 

Q: Have you ever had a loss of memory as a result of your drinking or drugging?   Y / N

 

Q: Has you physician ever treated you for drinking or using?   Y / N

 

Q: Do you drink or use to build up your self-confidence?   Y / N

 

Q: Have you ever been to a hospital or institution on account of drinking or using?   Y / N

 

 If you answered yes to 3 or more of these questions