1.
Do you feel you are a normal drinker?
Yes
No
2.
Have you ever awakened the morning after some
drinking the night before and found that you could
not remember a part of that evening?
Yes
No
3.
Do your friends or family ever worry or complain
about your drinking?
Yes
No
4.
Can you stop drinking without a struggle after
one or two drinks?
Yes
No
5.
Do you ever feel bad about your drinking?
Yes
No
6.
Do your friends or relatives think you are a
normal drinker?
Yes
No
7.
Do you ever try to limit your drinking to certain
times of the day or to certain places?
Yes
No
8.
Are you always able to stop drinking when you
want to?
Yes
No
9.
Have you ever attended a meeting of Alcoholics
Anonymous (AA) or any other group concerned about
drinking?
Yes
No
10.
Have you ever gotten into fights when drinking?
Yes
No
11.
Has your drinking ever created problems with you
and your friends or family?
Yes
No
12.
Have your friends or any family member ever gone
to anyone for help about your drinking?
Yes
No
13.
Have you ever lost a job or been suspended from
school because of your drinking?
Yes
No
14.
Have you ever gotten into trouble at school
because of your drinking?
Yes
No
15.
Have you ever lost friends because of your
drinking?
Yes
No
16.
Have you ever neglected your obligations, your
family, your work or your schoolwork for two or more
days in a row because you were drinking?
Yes
No
17.
Do you drink before noon?
Yes
No
18.
Have you ever been told you have liver trouble?
Yes
No
19.
Have you ever had delirium tremens (DTs), severe
shaking, heard voices, or seen things that were not
there after heavy drinking?
Yes
No
20.
Have you ever gone to anyone for help about your
drinking?
Yes
No
21.
Have you ever been to a hospital or emergency
room because of your drinking?
Yes
No
22.
Have you ever been a patient in a psychiatric
hospital, or a psychiatric ward in a general hospital,
where drinking was part of the problem?
Yes
No
23.
Have you ever been to a mental health clinic,
gone to a doctor, social worker, counselor, or
clergyman for help with an emotional problem in which
drinking played a part?
Yes
No
24.
Have you ever been arrested, even for a few hours,
because of drunk behavior?
Yes
No
25.
Have you ever been arrested for drunk driving or
driving after drinking?
Yes
No