Has anyone ever suggested you quit or cut back on your drug/alcohol use?

Yes

No

Has drinking or using affected your reputation?

Yes

No

Have you made promises to control your drinking or using and then broken them?

Yes

No

Have you ever switched to different drinks or drugs or changed your using pattern in an effort to control or reduce your consumption?

Yes

No

Have you ever gotten into financial, legal, or marital difficulties due to using?

Yes

No

Have you ever lost time from work because of using or drinking?

Yes

No

Have you ever sneaked or hidden your use?

Yes

No

On occasion, do you feel uncomfortable if alcohol or your drug is not available?

Yes

No

Do you continue drinking or using when friends or family suggest you have had enough?

Yes

No

Have you ever felt guilty or ashamed about your drinking or using or what you did while under the influence?

Yes

No

Has your efficiency decreased as a result of your drinking or using?

Yes

No

When using or drinking, do you neglect to eat properly?

Yes

No

Do you use or drink alone?

Yes

No

Do you use or drink more than usual when under pressure, angry, or depressed?

Yes

No

Are you able to drink or use more now without feeling it, compared to when you first started using?

Yes

No

Have you lost interest in other activities or noticed a decrease in your ambition as a result of your drinking or using?

Yes

No

Have you had the shakes or tremors following heavy drinking or using or not using for a period of time?

Yes

No

Do you want to drink or use at a particular time each day?

Yes

No

Do you go on and off the wagon?

Yes

No

Is drinking or using jeopardizing your job?

Yes

No

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Last Name

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I consent to have someone contacting me regarding the answers I provided above. *

Yes