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Answer these questions with a simple yes or no answer. Be totally honest with yourself as these questions are only for your use to know where you stand as far as alcohol use or drugs (licit or illicit) are concerned. The answers are only for you.

1. Do you feel you are a normal user of alcohol/drugs
2. Have you aver awakened in the morning after using alcohol/drugs the night before and found that you could not remember part of the evening?
3. Does your wife, husband, parent or other near relatives ever worry or complain about your using alcohol/drugs
4. Can you stop using alcohol/drugs without struggle after one or two drinks or doses?
5. Do you ever feel guilty after using alcohol/drugs?
6. Do your friends or relatives think your are a normal drinker/user?
7. Are you able to stop using alcohol/drugs when you want to?
8. Have you ever attended a meeting of Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)?
9. Have you ever got into fights when drinking/using drugs?
10. Has using alcohol/drugs ever created problems between you and your wife, husband parents or other near relatives?
11. Has your wife, husband, parent or other near relative ever gone to anyone for help about your using alcohol/drugs?
12. Have you ever lost friends, girlfriends or boyfriends because of your using alcohol/drugs?
13. Have you ever got into trouble at work because of your drinking or using drugs?
14. have you ever lost a job because of drinking or using drugs?
15. Have you ever neglected your obligations, your family or your work for two or more days in a row because you were drinking or using drugs?
16. Do you use alcohol/drugs before noon fairly often?
17. Have you ever been told you have liver trouble? Cirrhosis?
18. After heavy drinking/using drugs, have you ever had delirium tremens or severe shaking or heard voices or seen things that weren't really there?
19. Have you ever gone to anyone for help about drinking/using drugs?
20. Have you ever been in a hospital because of drinking/using drugs?
21. Have you ever been a patient at a psychiatric hospital or in a psychiatric ward of a general hospital where drinking/using drugs was part of the problem that resulted in hospitalization?
22. Have you ever been at a psychiatric or mental health clinic or gone to any doctor, social worker or clergyman for help with any emotional problem, where drinking or using drugs was part of the problem?
23. Have you ever been arrested for drunken behaviour?
24. have you ever been arrested, even for a few hours, because of other drunken behaviour?

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