Yes   No   

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

Yes   No   

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

Yes   No   

Does any near relative or close friend ever worry or complain about your drinking?

Yes   No   

Can you stop drinking without difficulty after one or two drinks?

Yes   No   

Do you ever feel guilty about your drinking?

Yes   No   

Have you ever attended a meeting of Alcoholics Anonymous (AA)?

Yes   No   

Have you ever gotten into physical fights when drinking?

Yes   No   

Has drinking ever created problems between you and a near relative or close friend?

Yes   No   

Has any family member or close friend gone to anyone for help about your drinking?

Yes   No   

Have you ever lost friends because of your drinking?

Yes   No   

Have you ever gotten into trouble at work because of drinking?

Yes   No   

Have you ever lost a job because of drinking?

Yes   No   

Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?

Yes   No   

Do you drink before noon fairly often?

Yes   No   

Have you engaged in illegal activities in order to obtain drugs?

Yes   No   

Have you ever been told you have liver trouble such as cirrhosis?

Yes   No   

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

Yes   No   

Have you ever gone to anyone for help about your drinking?

Yes   No   

Have you ever been hospitalized because of drinking?

Yes   No   

Has your drinking ever resulted in your being hospitalized in a psychiatric ward?

Yes   No   

Have you 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   

Have you been arrested more than once for driving under the influence of alcohol?

Yes   No   

Have you ever been arrested, even for a few hours, because of other behavior while drinking?