Q: Do you ever lose time at work because of drinking?

Yes
No

Q: Is drinking making your home life unhappy?

Yes
No

Q: Do you drink because you are shy with other people?

Yes
No

Q: Is drinking affecting your reputation?

Yes
No

Q: Have you ever felt remorse after drinking?

Yes
No

Q: Have you had financial difficulties as a result of drinking?

Yes
No

Q: Do you turn to inferior companions and environments when drinking?

Yes
No

Q: Does your drinking make you careless of your family’s welfare?

Yes
No

Q: Has your ambition decreased since drinking?

Yes
No

Q: Do you crave a drink at a definite time daily?

Yes
No

Q: Do you want a drink the next morning?

Yes
No

Q: Does drinking cause you to have difficulty in sleeping?

Yes
No

Q: Has your efficiency decreased since drinking?

Yes
No

Q: Is drinking jeopardizing your job or business?

Yes
No

Q: Do you drink to escape from worries or trouble?

Yes
No

Q: Do you drink alone?

Yes
No

Q: Have you ever had a loss of memory as a result of drinking?

Yes
No

Q: Has you physician ever treated you for drinking?

Yes
No

Q: Do you drink to build up your self-confidence?

Yes
No

Q: Have you ever been to a hospital or institution because of drinking?

Yes
No

 

Source: Office of Health Care Programs, Johns Hopkins University Hospital