| | Yes | No |
1. | Do you need a drink at a definite time every day? | | |
2. | Do you prefer drinking alone? | | |
3. | Do you find yourself getting drunk every time you drink? | | |
4. | When you drink, do you have loss of memory or blackouts? | | |
5. | Do you have the shakes after drinking? | | |
6. | Do you get the inner shakes unless you continue drinking? | | |
7. | Do you sneak your drinks? | | |
8. | Do you have weekend drinks? | | |
9. | Do you have mid-week drinks? | | |
10. | Do you crave a drink in the morning? | | |
11. | Do you hide your drink or protect the supply? | | |
12. | Do you avoid food when drinking? | | |
13. | Do you lose time from work when drinking? | | |
14. | Has your initiative, ambition, or perseverance decreased? | | |
15. | Has drinking made you careless of your family’s welfare? | | |
16. | Do you turn to an inferior environment while drinking? | | |
17. | Do you show marked moodiness as a result of drinking? | | |
18. | Is it jeopardizing your job, business or career? | | |
19. | Has it made you irritable or belligerent? | | |
20. | Have you ever admitted to yourself or another that you were unable to control your drinking? | | |
21. | Has your drinking made you sensitive? | | |
22. | Do you become argumentative when drinking? | | |
23. | Is it endangering your health? | | |
24. | Is it making your home life unhappy? | | |
25. | When drinking, do you wake up early in the morning? | | |
26. | While drinking, are you restless in your sleep? | | |
27. | Do you drink to relieve feelings of inadequacy? | | |
28. | Has drinking made you harder to get along with? | | |
29. | Have you ever felt a religious need? | | |
30. | While drinking, have you become extravagant in behavior? | | |
31. | Has your drinking pattern changed? | | |
32. | Do you ever have a remorse feeling while drinking? | | |
33. | Do you have any antisocial behavior? | | |
34. | Do you become jealous of your husband or wife? | | |
35. | Is it affecting your peace of mind? | | |
36. | Have you lost any friends as a result of drinking? | | |
37. | Have you lost any jobs as a result of drinking? | | |
38. | Do you continually seek occasions for drinking? | | |
39. | Has your life become alcohol centered? | | |
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