Alcoholism

1. Do you feel they are a normal drinker? ("normal" - drink as much or less than most other people)?

• Yes
• No

2. Have they ever awakened the morning after some drinking the night before and found that they could not remember a part of the evening?

• Yes
• No

3. Do you or any close friends ever worry or complain about their drinking?

• Yes
• No

4. Can they stop drinking without difficulty after one or two drinks?

• Yes
• No

5. Do they ever feel guilty about their drinking?

• Yes
• No

6. Have they ever attended a meeting of Alcoholics Anonymous (AA)?

• Yes
• No

7. Have they ever gotten into physical fights when drinking?

• Yes
• No

8. Has their drinking ever created problems between you?

• Yes
• No

9. Have you, a family member or close friend gone to anyone for help about their drinking?

• Yes
• No

10. Have they ever lost friends because of their drinking?

• Yes
• No

11. Have they ever gotten into trouble at work because of drinking?

• Yes
• No

12. Have they ever lost a job because of drinking?

• Yes
• No

13. Have they ever neglected their obligations, their family, or their work for two or more days in a row because they were drinking?

• Yes
• No

14. Do they drink before noon fairly often?

• Yes
• No

15. Have they ever been told they have liver trouble such as cirrhosis?

• Yes
• No

16. After heavy drinking have they ever had delirium tremens (D.T.'s), severe shaking, visual or auditory (hearing) hallucinations?

• Yes
• No

17. Have they ever gone to anyone for help about their drinking?

• Yes
• No

18. Have they ever been hospitalized because of drinking?

• Yes
• No

19. Has their drinking ever resulted in being hospitalized in a psychiatric ward?

• Yes
• No

20. Have they ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem?

• Yes
• No

21. Have they ever been arrested for driving under the influence of alcohol?

• Yes
• No

22. Have they been arrested, even for a few hours, because of other behavior while drinking?

• Yes
• No