1. Do you drink heavily when you are disappointed, under pressure or have had a quarrel with someone? |
Yes No |
2. Can you handle more alcohol now than when you first started to drink? |
Yes No |
3. Have you ever been unable to remember part of the previous evening, even though your friends say you didn’t pass out? |
Yes No |
4. When drinking with other people, do you try to have a few extra drinks when others won’t know about it? |
Yes No |
5. Do you sometimes feel uncomfortable if alcohol is not available? |
Yes No |
6. Are you more in a hurry to get your first drink of the day than you used to be? |
Yes No |
7. Do you sometimes feel a little guilty about your drinking? |
Yes No |
8. Has a family member or close friend express concern or complained about your drinking? |
Yes No |
9. Have you been having more memory “blackouts” recently? |
Yes No |
10. Do you often want to continue drinking after your friends say they’ve had enough? |
Yes No |
11. Do you usually have a reason for the occasions when you drink heavily? |
Yes No |
12. When you’re sober, do you sometimes regret things you did or said while drinking? |
Yes No |
13. Have you tried switching brands or drinks, or following different plans to control your drinking? |
Yes No |
14. Have you sometimes failed to keep promises you made to yourself about controlling or cutting down on your drinking? |
Yes No |
15. Have you ever had a DWI (driving while intoxicated) or DUI (driving under the influence of alcohol) violation, or any other legal problem related to your drinking? |
Yes No |
16. Do you try to avoid family or close friends while you are drinking? |
Yes No |
17. Are you having more financial, work, school, and/or family problems as a result of your drinking? |
Yes No |
18. Has your physician ever advised you to cut down on your drinking? |
Yes No |
19. Do you eat very little or irregularly during the periods when you are drinking? |
Yes No |
20. Do you sometimes have the “shakes” in the morning and find that it helps to have a “little” drink, tranquilizer or medication of some kind? |
Yes No |
21. Have you recently noticed that you can’t drink as much as you used to? |
Yes No |
22. Do you sometimes stay drunk for several days at a time? |
Yes No |
23. After periods of drinking do you sometimes see or hear things that aren’t there? |
Yes No |
24. Have you ever gone to anyone for help about your drinking? |
Yes No; |
25. Do you ever feel depressed or anxious before, during or after periods of heavy drinking? |
Yes No |
26. Have any of your blood relatives ever had a problem with alcohol? |
Yes No |