Substance Dependency Questionnaire

Click Yes or No for each question. Click the Submit button when completed.

1. Do you lose time from work due to drinking/using? Yes
No
2. Is drinking/using making your home life unhappy? Yes
No
3. Do you drink/use because you are shy with other people? Yes
No
4. Is drinking/using affecting your reputation? Yes
No
5. Have you ever felt remorse after drinking/using? Yes
No
6. Have you gotten into financial difficulties as a result of drinking/using? Yes
No
7. Do you turn to lower companions and an inferior environment when drinking/using? Yes
No
8. Does your drinking/using make you careless of your family's welfare? Yes
No
9. Has your ambition decreased since you started drinking/using? Yes
No
10. Do you crave a drink or drug at a definite time daily? Yes
No
11. Do you want a drink or drug in the morning? Yes
No
12. Does drinking/using cause you to have difficulty sleeping? Yes
No
13. Has your efficiency decreased since you started drinking/using? Yes
No
14. Is drinking/using jeopardizing your job or business? Yes
No
15. Do you drink/use to escape from worries or trouble? Yes
No
16. Do you drink/use alone? Yes
No
17. Have you ever had a complete loss of memory as a result of drinking/using? Yes
No
18. Has your physician ever treated you for drinking/using? Yes
No
19. Do you drink/use to build up your self-confidence? Yes
No
20. Have you ever been to a hospital or institution on account of drinking/using? Yes
No