1. Do you drink alone?  

Yes No

2. Does your drinking cause you to lose time from work?

Yes No

3. Do you have job problems due to your drinking?

Yes No

4. Do you hide your alcohol consumption or the actual alcohol?

Yes No

5. Is your drinking making your home life unhappy?

Yes No

6. Do you forget things while or after drinking?

Yes No

7. Do you drink because you are shy with others?

Yes No

8. Do you have health problems caused by your drinking?

Yes No

9. Have you ever felt remorse after drinking?

Yes No

10. Do you use alcohol to make you relax?

Yes No

11. Have you had financial difficulties as a result of drinking?

Yes No

12. Have you tried to cut down or quit drinking?

Yes No

13. Have you had legal problems due to drinking?

Yes No

14. Do you crave a drink at a definite time each day?

Yes No

15. Do you want a drink the next morning?

Yes No

16. Does drinking cause you to have problems sleeping?

Yes No

17. Do you drink to escape from worries or troubles?

Yes No

18. Do you feel you have a drinking problem?

Yes No