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ALCOHOLISM SCREENING  (800)227-3953

Check the appropriate response for each of the following questions.

Please use the mouse to move from one question to the next.

Do not use the 'Enter' key or the form will be submitted prematurely.

Do you feel you are a normal drinker? (By normal we mean you drink less or as much as most other people.)

Yes
No

Have you ever awakened in the morning after some drinking the night before and found that you could not remember a part of the evening?

Yes
No

Does your wife, husband, a parent or other relative ever worry or complain about your drinking?

Yes
No

Can you stop drinking without a struggle after one or two drinks?

Yes
No

Do you ever feel guilty about your drinking?

Yes
No

Do friends and relatives think you are a normal drinker?

Yes
No

Are you able to stop drinking when you want to?

Yes
No

Have you ever attended a meeting of Alcoholics Anonymous (AA)?

Yes
No

Have you ever gotten into physical fights when drinking?

Yes
No

Has your drinking ever created problems between you and your wife, husband, a parent, or other relative?

Yes
No

Has your wife, husband (or other family members) ever gone to anyone for help about your drinking?

Yes
No

Have you ever lost friends because of your drinking?

Yes
No

Have you ever gotten into trouble at work or school because of your drinking?

Yes
No

Have you ever lost a job because of drinking?

Yes
No

Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?

Yes
No

Do you drink before noon fairly often?

Yes
No

Have you ever been told your have liver trouble? Cirrhosis?

Yes
No

After heavy drinking, have you ever had Delirium Tremens (D.T.'s) or severe shaking, or heard voices, or seen things that weren't really there?

Yes
No

Have you ever gone to anyone for help about your drinking?

Yes
No

Have you ever been hospitalized because of drinking?

Yes
No

Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was part of the problem that resulted in hospitalization?

Yes
No

Have you ever been seen at a psychiatric or mental health clinic or gone to any doctor, social worker, or clergyman for help with any emotional problem, where drinking was part of the problem?

Yes
No

Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages?

Yes
No

If yes, how many times?

1
2
3 or more

Have you ever been arrested or taken into custody, even for a few hours, because of other drunk behavior?

Yes
No

If yes, how many times?

1
2
3 or more

The test results will be returned to you as a web page immediately after you submit the test.

The results WILL NOT be saved, e-mailed, or in any way be available to, or read by, anyone.

Click the "Finish" button to proceed to the results page.

Note: This is only a screening instrument and should not be used as the sole determinant of a problem. It is recommended that a complete evaluation, using other instruments, be used and interpreted by a qualified professional.