Is a family member, friend, co-worker or doctor hinting or even telling you that they think there is a problem?
Yes No
Are your family or friends saying they wish you could be the way you used to be?
Yes No
Have you decided to stop using alcohol or drugs just to find you've started again?
Yes No
Do you become annoyed or irritated when others broach the subject with you?
Yes No
Have you ever hidden drugs or alcohol?
Yes No
Do you have a secret emergency supply of alcohol or drugs?
Yes No
Have you ever driven under the influence of alcohol or drugs?
Yes No
Have you ever blacked out while using?
Yes No
Have you ever been on a drug or alcohol binge?
Yes No
Have you changed doctors to maintain your prescription supply?
Yes No
Have you received the same prescription from two or more doctors at the same time?
Yes No
Have you been "pharmacy shopping" to get the amount of drugs you need?
Yes No
Have you ever been turned down for a refill?
Yes No
Have you ever forged a prescription?
Yes No
Have you ever endangered yourself by buying drugs off the street?
Yes No
Have you ever sold favors for drugs?
Yes No
Have you ever not been able to remember how you got home?
Yes No
Have you felt great remorse over anything you have done while under the influence of drugs or alcohol?
Yes No
Have you told yourself repeatedly this is the last time?
Yes No
Do you cancel or just not turn up for appointments and meetings when using?
Yes No
Have others commented about your change of personality?
Yes No
Have you been embarrassed by your behavior when under the influence of drugs or alcohol?
Yes No
Have your children ever asked what is wrong with you?
Yes No
Has anybody cut off a relationship with you because of the behavior associated with your drug or alcohol use?
Yes No
Have you ever lost a job because of your inability to perform?
Yes No
Have you ever lost things and don't know what happened to them?
Yes No
Do you ever hide your drinking?
Yes No
Do you lie about your alcohol consumption and drug use?
Yes No
Do you refuse to discuss your drug or alcohol use?
Yes No
Will you be professionally threatened if you reveal your drug or alcohol use?
Yes No
Do you ever feel great shame over your use?
Yes No
Is your use increasing?
Yes No
Is your tolerance increasing?
Yes No
Is your secret despair increasing?
Yes No
Do you find it impossible to stop for any prolonged period of time?
Yes No