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