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01. | Do you lose time from work
due to drinking? | Yes | No |
|
02. | Is
drinking making your home life
unhappy? | Yes | No |
|
03. | Do you drink because you
are shy with other people? | Yes | No |
|
04. | Is drinking affecting your
reputation? | Yes | No |
|
05. | Have you ever felt remorse
after drinking? | Yes | No |
|
06. | Have you ever got into
financial difficulties as a result of
drinking? | Yes | No |
|
07. | Do you turn to lower
companions and an inferior environment when
drinking? | Yes | No |
|
08. | Does drink make you
careless of your family's welfare? | Yes | No |
|
09. | Has your ambition
decreased since drinking? | Yes | No |
|
10. | Do you crave for a drink
at a definite time daily? | Yes | No |
|
11. | Do you want a drink the
next morning? | Yes | No |
|
12. | Does drinking cause you to
have difficulty in sleeping? | Yes | No |
|
13. | Has your efficiency
decreased since drinking? | Yes | No |
|
14. | Is drinking jeopardizing
your job or business? | Yes | No |
|
15. | Do you drink to escape
from worries or trouble? | Yes | No |
|
16. | Have you ever had a
complete loss of memory as a result of
drinking? | Yes | No |
|
17. | Do you
drink
alone? | Yes | No |
|
18. | Has a physician ever
treated you for drinking? | Yes | No |
|
19. | Do you drink to build up
your self-confidence? | Yes | No |
|
20. | Have you ever been in a
hospital or institution on account of
drinking? | Yes | No |