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0. Do you enjoy a drink now and then? |
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1. Do you feel you are a normal drinker? (By normal we
mean, you drink less than or more than
 most
people)
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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?
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3. Does your wife, husband, a parent or other relative ever worry or complain about your
drinking?
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4. Can you stop drinking without a struggle after 1 or 2 drinks? * |
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5. Do you feel guilty about your drinking? |
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6. Do friends and relatives think you are a normal drinker? |
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7. Are you able to stop drinking when you want to? |
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8. Have you ever attended a meeting of Alcoholics Anonymous? |
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9. Have you gotten into physical fights when drinking? |
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10. Has drinking ever created problems between you and your wife, husband, a parent, or other
relative?
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11. Has your wife, husband (or other family members) ever gone to anyone for help about your
drinking?
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12. Have you ever lost friends because of your drinking? |
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13. Have you ever gotten into trouble at work because
of drinking? |
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14. Have you ever lost your job because of alcoholism? |
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15. Have you ever neglected your obligations, your family, or your work for 2 or more days in a
row because you were drinking?
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16. Do you drink before noon fairly often? |
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17. Have you ever been told you have liver problems? Cirrhosis? |
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18. After heavy drinking, have you ever had the DTs (Delirium Tremens) or severe shaking, or
heard voices, or seen things that weren't really there? **
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19. Have you ever gone to anyone for help about your drinking? |
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20. Have you ever been in a hospital because of drinking? |
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21. Have you ever been a patient in a psychiatric hospital or a psychiatric ward of a general
hospital where drinking was part of the problem that resulted in your hospitalization?
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22. Have you ever been seen at a psychiatric or mental health clinic or gone to any doctor, social
worker, or clergyman for help with any emotional problems, where drinking was part of the
problem?
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23. Have you ever been arrested for drunk driving (D.U.I.), or driving while intoxicated (D.W.I.)?
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24. Have you ever been arrested, or taken into custody, even for a few hours because of other
drunk behavior? ***
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