This short questionnaire is designed to help identify symptoms and warning signs of a current or potential problem with alcohol or other drugs.* Please read each statement, recording the indicated numeric score for your true or false response. *Please note: “Drug” refers to any mood-altering substance, including prescription medication. 1. My use of alcohol or other drugs has increased over the past year. (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) 2. I have attempted to cut down on how much or how often I drink or use other drugs but have not been very consistent. (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) 3. I have lied or minimized to family or friends about how much, or how often I drink or use other drugs. (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) 4. I drink or use other drugs even when I have planned not to. (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) 5. In the last year I have said to myself, or others, “I can quit any time,” or, “I don’t have a problem.” (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) 6. On more than one occasion I could not remember some things that happened while I was drinking or using other drugs. (If answer is true, give yourself 2 points.)
(If answer is false, give yourself 0 points.) 7. On more than one occasion, I have said or done things while using alcohol or other drugs that I deeply regret. (If answer is true, give yourself 2 points.)
(If answer is false, give yourself 0 points.) 8. My use of alcohol or other drugs has caused tension or problems in at least one of my most important relationships. (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) 9. In the last year, I have missed work or school because of alcohol or other drugs. (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) 10. I have had accidents or been injured as a result of drinking or drug use. (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) 11. I have legal problems related to drinking or drug use. (If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.) Results
Total your score. If your score is: 0 points: Based on your responses to the questionnaire you do not appear to have a current problem with substance abuse. However, if you completed this questionnaire because you are concerned about your use of alcohol or other drugs, you may want to learn more. 1 to 3 points: Your score indicates that you currently are experiencing some of the symptoms associated with substance abuse. Substance abuse is a progressive problem with potentially devastating consequences. 4 or more points: Your score indicates that you currently are experiencing many of the symptoms associated with substance abuse. Substance abuse is progressive and characterized by repeated harmful consequences. |