Date

MM

DD

YYYY

Name *

First Name

Last Name

1. Have you ever lost time from school or work due to drinking or getting high?

Yes

No

2. Have you ever felt uncomfortable if alcohol or drugs are not available at social functions?

Yes

No

3. Do you think your use of alcohol or drugs has caused you or your family to spend any money on fines, damages, lawyer fees, restitution, bail, etc.?

Yes

No

4. Have you ever drank or gotten high alone?

Yes

No

5. Has anyone ever expressed their concern about your use of alcohol or drugs?

Yes

No

6. Have you ever drank or gotten high shortly after you have had a problem at home, work or school?

Yes

No

7. Have you ever tried to quit or cut back on your use of alcohol or drugs, but were not able to do it?

Yes

No

8. Has it ever bothered you if someone says that you drink or get high too much?

Yes

No

9. Do you usually take a drink or get high when you go out on a date?

Yes

No

10. Have you drank or gotten high before school or work or during school or work?

Yes

No

11. Have you ever neglected responsibilities at home, work or school to drink or get high?

Yes

No

12. Has there ever been someone in your family with a drinking or drug problem?

Yes

No

13. Do you think you can drink or use more now then when you first started?

Yes

No

14. Do you like to drink or get high when you start your day?

Yes

No

15. Do most of your friends drink or get high?

Yes

No

16. Do you like to drink or get wasted on alcohol and/or drugs?

Yes

No

17. Have you ever been arrested, apprehended by school officials or sent to a program because of alcohol or drug related offenses?

Yes

No

18. Have you ever had a complete loss of memory from drinking or using drugs?

Yes

No

19. Have you drank or gotten high where your friends could not see you in such places as garages, restrooms, etc.?

Yes

No

20. Could you have a problem with alcohol or drugs?

Yes

No