1. Do you feel you are a normal drinker? (“normal”—drink as much or less than most other people) YES or NO
  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? YES or NO
  3. Does any near relative or close friend ever worry or complain about your drinking? YES or NO
  4. Can you stop drinking without difficulty after one or two drinks? YES or NO
  5. Do you ever feel guilty about your drinking? YES or NO
  6. Have you ever attended a meeting of Alcoholics Anonymous (AA)? YES or NO
  7. Have you ever gotten into physical fights when drinking? YES or NO
  8. Has drinking ever created problems between you and a near relative or close friend? YES or NO
  9. Has any family member or close friend gone to anyone for help about your drinking? YES or NO
  10. Have you ever lost friends because of your drinking? YES or NO
  11. Have you ever gotten into trouble at work because of drinking? YES or NO
  12. Have you ever lost a job because of drinking? YES or NO
  13. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking? YES or NO
  14. Do you drink before noon fairly often? YES or NO
  15. Have you ever been told you have liver trouble such as cirrhosis? YES or NO
  16. After heavy drinking have you ever had delirium tremens (D.T.’s), severe shaking, visual or auditory (hearing) hallucinations? YES or NO
  17. Have you ever gone to anyone for help about your drinking? YES or NO
  18. Have you ever been hospitalized because of drinking? YES or NO
  19. Has your drinking ever resulted in your being hospitalized in a psychiatric ward? YES or NO
  20. Have you ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem? YES or NO
  21. Have you been arrested more than once for driving under the influence of alcohol? YES or NO
  22. Have you ever been arrested, even for a few hours because of other behavior while drinking? (If Yes, how many times ________ ) YES or NO



© 2018 Scott Stevens

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