1. Do you drink or use to feel more confident or overcome shyness?: Yes No 2. Are you having money problems because of drinking or using?: Yes No 3. Are you ever absent from work because of drinking or using?: Yes No 4. Have you been fired or lost a business because of drinking or using?: Yes No 5. Have you been admitted to the hospital because of drinking or using?: Yes No 6. Do you have a bad reputation from drinking or using?: Yes No 7. Do you drink or use when you are alone?: Yes No 8. Do you feel remorse after drinking or using?: Yes No 9. Do you drink in the morning?: Yes No 10. Is your family suffering from your drinking or using?: Yes No 11. Do you drink or use to escape your problems?: Yes No 12. Do you make promises to yourself or others about your drinking or using?: Yes No 13. Have you had an accident because of drinking or using?: Yes No 14. Do you have poor judgment about the people you are with and the places you go when you are drinking or using?: Yes No 15. Have you been arrested more than once for drunk driving or driving under the influence of drugs?: Yes No 16. Is your health affected by your drinking or using?: Yes No 17. Do you drink or use to relieve the painfulness of living?: Yes No 18. Once you have started, do you have to keep on drinking or using?: Yes No 19. Do you have blackouts? (Forgetting events that happened or actions you performed while drinking or using?): Yes No 20. Has a doctor ever treated you for your drinking or using?: Yes No
1. Do you drink or use to feel more confident or overcome shyness?: Yes No 2. Are you having money problems because of drinking or using?: Yes No 3. Are you ever absent from work because of drinking or using?: Yes No 4. Have you been fired or lost a business because of drinking or using?: Yes No 5. Have you been admitted to the hospital because of drinking or using?: Yes No 6. Do you have a bad reputation from drinking or using?: Yes No 7. Do you drink or use when you are alone?: Yes No 8. Do you feel remorse after drinking or using?: Yes No 9. Do you drink in the morning?: Yes No 10. Is your family suffering from your drinking or using?: Yes No 11. Do you drink or use to escape your problems?: Yes No 12. Do you make promises to yourself or others about your drinking or using?: Yes No 13. Have you had an accident because of drinking or using?: Yes No 14. Do you have poor judgment about the people you are with and the places you go when you are drinking or using?: Yes No 15. Have you been arrested more than once for drunk driving or driving under the influence of drugs?: Yes No 16. Is your health affected by your drinking or using?: Yes No 17. Do you drink or use to relieve the painfulness of living?: Yes No 18. Once you have started, do you have to keep on drinking or using?: Yes No 19. Do you have blackouts? (Forgetting events that happened or actions you performed while drinking or using?): Yes No 20. Has a doctor ever treated you for your drinking or using?: Yes No
