|
YES |
NO |
| Do you drink
alone? |
___ |
___ |
| Does your
drinking cause you to lose time from work? |
___ |
___ |
| Do you have job
problems due to your drinking? |
___ |
___ |
| Do you hide
your alcohol consumption or the actual alcohol? |
___ |
___ |
| Is your
drinking making your home life unhappy? |
___ |
___ |
| Do you forget
thinks while or after drinking? |
___ |
___ |
| Do you drink
because you are shy with others? |
___ |
___ |
| Do you have
health problems caused by your drinking? |
___ |
___ |
| Have you ever
felt remorse after drinking? |
___ |
___ |
| Do you use
alcohol to make you relax? |
___ |
___ |
| Have you had
financial difficulties as a result of drinking? |
___ |
___ |
| Have you tried
to cut down or quit drinking? |
___ |
___ |
| Have you had
legal problems due to drinking? |
___ |
___ |
| Do you crave a
drink at a definite time each day? |
___ |
___ |
| Do you want a
drink the next morning? |
___ |
___ |
| Does drinking
cause you to have problems sleeping? |
___ |
___ |
| Do you drink to escape from worries or
troubles? |
___ |
___ |
| Do you feel you
have a drinking problem? |
___ |
___ |