| Click in this frame, print frame, and circle your answer. | |||
| 1. | Do you feel that you are a normal drinker? | YES | NO |
| 2. | Have you ever awakened the morning after some drinking the night before and found you could not remember a part of the evening before? | YES | NO |
| 3. | Does your spouse (or parent) 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)? | YES | NO |
| 10. | Have you gotten into fights when drinking? | YES | NO |
| 11. | Has drinking ever created problems with you and your spouse? | YES | NO |
| 12. | Has your spouse (or other family members) ever gone to anyone for help about your drinking? | YES | NO |
| 13. | Have you ever lost friends, girlfriends, or boyfriends because of drinking? | YES | NO |
| 14. | Have you ever gotten into trouble at work because of drinking? | YES | NO |
| 15. | Have you ever lost a job because of drinking? | YES | NO |
| 16. | Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking? | YES | NO |
| 17. | Do you ever drink before noon? | YES | NO |
| 18. | Have you ever been told you have cirrhosis (liver trouble)? | YES | NO |
| 19. | Have you ever had delirium tremors (DT's), severe shaking, heard voices, or seen things that weren't 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 hospitalized because of drinking? | YES | NO |
| 22. | Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was part of the problem? | YES | NO |
| 23. | Have you ever been seen at a psychiatric or mental health clinic, or gone to a doctor, social worker, or clergyman for help with an emotional problem in which drinking has played a part? | YES | NO |
| 24. | Have you ever been arrested, even for a few hours, because of drunken behavior? | YES | NO |
[Go to answer page for scoring]
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