|
# |
Questions |
yes |
no |
|
1 |
Do
you lose time from work due to your drinking or drugging? |
|
|
|
2 |
Is
drinking/drugging causing problems in your home life? |
|
|
|
3 |
Do
you drink or use drugs because you are shy when around people? |
|
|
|
4 |
Have
you been to a hospital due to drinking/drugging? |
|
|
|
5 |
Is
your reputation being affected by your drinking/drugging? |
|
|
|
6 |
Are
you alone when you drink or use drugs? |
|
|
|
7 |
Have
you experienced memory loss due to drinking/drugging? |
|
|
|
8 |
Do
you crave for a drink/drugs at a certain time every day? |
|
|
|
9 |
Do
you want a drink/drug the next morning? |
|
|
| 10 |
Do
you resort to drinking/drugging in an inferior environment? |
|
|
| 11 |
Do
have trouble sleeping due to drinking/drugging? |
|
|
| 12 |
Have
you had financial trouble due to drinking/drugging? |
|
|
| 13 |
Have
you ever felt remorse for your drinking/drugging? |
|
|
| 14 |
Is
your job in jeopardy due to your drinking/drugging? |
|
|
| 15 |
Do
you drink/ use drugs to feel more confident and self-assured? |
|
|
| 16 |
Do
you drink/ use drugs to escape from you problems and worries? |
|
|
