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