Drug and Alcohol Assessment Form

Do you have a problem with alcohol or other drugs?

Questions
YES
NO
1. Do you drink or use drugs to overcome shyness or to feel more confident?
2. Are you having money troubles because of drinking or using drugs?
3. Do you ever stay home from work because of drinking or drug use?
4. Is drinking or using drugscausing trouble in your family?
5. Is drinking or using drugs giving you a bad reputation?
6. Have you lost a job or a business because of drinking or drug use?
7. Do you drink or use drugs to escape your problems?
8. Do you drink or use drugs when you are alone?
9. Do you have blackouts? (Loss of memory for events that happened or of actions you performed while drinking or drug use?)
10. Do you feel remorse after drinking or using drugs?
11. Do you need a drink or use drugs at a definite time every day?
12. Do you drink or use drugs in the morning?
13. Have you ever been in a hospital because of drinking or using drugs?
14. Has a doctor ever treated you for your drinking or using drugs?
15. Do you drink or use too many drugs at the wrong time?
16. Do you make promises to yourself or others about your drinking or drug use?
17. Do you have to keep on drinking or using drugs once you have started?
18. Is drinking or using drugs making it hard for you to sleep?
19. Have you had an accident because of drinking or drug use?
20. Do you drink or use drugs to relieve the painfulness of living?
21. Do you have trouble disposing of cans or bottles?
22. Are you less particular about people you are with and the places you go when you are drinking or using drugs?
23. Have you been arrested more than once for drunk driving or driving under the influence of drugs?
24. Has drinking or using drugs affected your health?

Your “YES” answer total:

One “YES” answer:
BE AWARE.  You may have or you may develop a problem with alcohol or other drugs.

Two or more “YES” answers:
Indicates you have problems with alcohol and/or drugs and should seek help immediately.

If you believe that you have or that you may have a problem with alcohol or other drugs, we can help.