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

                             
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