During the last 6 months...


1. Have you used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or other opioids, uppers, downers, hallucinogens, or inhalants)
           Yes         No
   
   
2. Have you felt that you use too much alcohol or other drugs?
           Yes         No
   
   
3. Have you tried to cut down or quit drinking or using alcohol or other drugs?
           Yes         No
   
   
4. Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.)
           Yes         No
   
   
5. Have you had any health problems? For example, have you:
           Had blackouts or other periods of memory loss?
           Injured your head after drinking or using drugs?
           Had convulsions, delirium tremens (“DTs”)?
           Had hepatitis or other liver problems?
           Felt sick, shaky, or depressed when you stopped?
           Felt “coke bugs” or a crawling feeling under the skin
                    after you stopped using drugs?
           Been injured after drinking or using?
           Used needles to shoot drugs?
   
   
6. Has drinking or other drug use caused problems between you and your family or friends?
           Yes         No
   
   
7. Has your drinking or other drug use caused problems at school or at work?
           Yes         No
   
   
8. Have you been arrested or had other legal problems? (Such as bouncing bad checks, driving while intoxicated, theft, or drug possession.)
           Yes         No
   
   
9. Have you lost your temper or gotten into arguments or fights while drinking or using other drugs?
           Yes         No
   
   
10. Do you need to drink or use drugs more and more to get the effect you want?
            Yes         No
    
    
11. Do you spend a lot of time thinking about or trying to get alcohol or other drugs?
            Yes         No
    
    
12. When drinking or using drugs, are you more likely to do something you wouldn't normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone?
            Yes         No
    
    
13. Do you feel bad or guilty about your drinking or drug use?
            Yes         No
    
    
The next questions are about your lifetime experiences.


14. Have you ever had a drinking or other drug problem?
            Yes         No
    
    
15. Have any of your family members ever had a drinking or drug problem?
            Yes         No
    
    
16. Do you feel that you have a drinking or drug problem now?
            Yes         No
    
    

If your score is 4 or greater, you may be at risk for alcohol-or-drug-related problems. You may want to call 1-800-ALCOHOL for help or guidance.