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Date:
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1. How often do you have a drink containing alcohol?
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2. How many drinks containing alcohol do you have on a typical day when you are drinking?
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3. How often do you have five or more drinks on one occasion?
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4. How often during the last year have you found that you were not able to stop drinking once you had started?
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5. How often during the last year have you failed to do what was normally expected of you because of drinking?
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6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking sess
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7. How often during the last year have you had a feeling of guilt or remorse after drinking?
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8. How often during the last year have you been unable to remember what happened the night before because of your drinking?
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9. Have you or someone else been injured because of your drinking?
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10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
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Have you ever been in treatment for an alcohol problem?
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