¹
Yes
No
1
Do you feel you are a normal drinker?
2
Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening before?
3
Does your wife (or parents) ever worry or complain about your drinking?
4
Can you stop drinking without a struggle after one or two drinks?
5
Do you ever feel bad about your drinking?
6
Do friends or relatives think you are a normal drinker?
7
Do you ever try to limit your drinking to certain times of the day or to certain places?
8
Are you always able to stop drinking when you want to?
9
Have you ever attended a meeting of Alcoholics Anonymous (AA)?
10
Have you gotten into fights when drinking?
11
Has drinking ever created problems between you and your wife?
12
Has your wife (or other family member) ever gone for anyone for help about your drinking?
13
Have you ever lost friends or girlfriends/boyfriends because of drinking?
14
Have you ever gotten into trouble at work because of drinking?
15
Have you ever lost a job because of drinking?
16
Have you ever neglected your obligations, your family or your work for two or more days in a row because you were drinking?
17
Do you ever drink before noon?
18
Have you ever been told you have liver trouble? Cirrhosis?
19
Have you ever had delirium tremens (DTs), severe shaking, heard voices or seen things that weren't there after heavy drinking?
20
Have you ever gone to anyone for help about your drinking?
21
Have you ever been in a hospital because of drinking?
22
Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was a part of the problem?
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?
24
Have you ever been arrested, even for a few hours, because of drunk behavior?
25
Have you ever been arrested for drunk driving after drinking?