Name *

First Name

Last Name

Do you lose time from work due to your drinking?

Yes

Sometimes

No

Is your drinking making your home life unhappy?

Yes

Sometimes

No

Do you drink because you are shy with other people?

Yes

Sometimes

No

Is drinking affecting your reputation?

Yes

Sometimes

No

Have you ever felt remorse after drinking?

Yes

Sometimes

No

Have you gotten into financial difficulties as a result of your drinking?

Yes

Sometimes

No

Do you turn to lower companions and an inferior environment when drinking?

Yes

Sometimes

No

Does your drinking make you careless of your family's welfare?

Yes

Sometimes

No

Has your ambition decreased since drinking?

Yes

Sometimes

No

Do you crave a drink at a definite time daily?

Yes

Sometimes

No

Do you want a drink the next morning?

Yes

Sometimes

No

Does drinking cause you to have difficulty in sleeping?

Yes

Sometimes

No

Has your efficiency decreased since drinking?

Yes

Sometimes

No

Is drinking jeopardizing your job or business?

Yes

Sometimes

No

Do you drink to escape from worries or troubles?

Yes

Sometimes

No

Do you drink alone?

Yes

Sometimes

No

Have you ever had a complete loss of memory as a result of your drinking?

Yes

Sometimes

No

Has your physician ever treated you for drinking?

Yes

Sometimes

No

Do you drink to build up your self-confidence?

Yes

Sometimes

No

Have you ever been in a hospital or institution on account of drinking?

Yes

Sometimes

No