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Drug and Alcohol Assessment Form
Do you have a problem with alcohol or other drugs?
Please answer "yes" or "no" to the following questions. 1. Do you drink or use drugs to overcome shyness or to feel more confident? Yes No
2. Are you having money troubles because of drinking or using drugs? Yes No
3. Do you ever stay home from work because of drinking or using drugs? Yes No
4. Is drinking or using drugs causing trouble in your family? Yes No
5. Is drinking or using drugs giving you a bad reputation? Yes No
6. Have you lost a job or a business because of drinking or drug use? Yes No
7. Do you drink or use drugs to escape your problems? Yes No
8. Do you drink or use drugs when you are alone? Yes No
9. Do you have blackouts? (Loss of memory for events that happened or of actions you performed while drinking or drug use?) Yes No
10. Do you feel remorse after drinking or using drugs? Yes No
11. Do you need a drink or use drugs at a definite time every day? Yes No
12. Do you drink or use drugs in the morning? Yes No
13. Have you been in a hospital because of drinking or using drugs? Yes No
14. Has a doctor ever treated you for your drinking or using drugs? Yes No
15. Do you drink or use too many drugs at the wrong time? Yes No
16. Do you make promises to yourself or others about your drinking or drug use? Yes No
17. Do you have to keep on drinking or using drugs once you have started? Yes No
18. Is drinking or using drugs making it hard for you to sleep? Yes No
19. Have you had an accident because of drinking or drug use? Yes No
20. Do you drink or use drugs to relieve the painfulness of living? Yes No
21. Do you have trouble disposing of cans or bottles? Yes No
22. Are you particular about people you are with and the places you go when you are drinking or using drugs? Yes No
23. Have you been arrested more than once for drunk driving or driving under the influence? Yes No
24. Has drinking or using drugs affected your health? Yes No
Go to the "ABOUT US" page for your test results
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