Do you lose time from work due to drinking?

    Yes
    No

Is drinking making your home life unhappy?

    Yes
    No

Do you drink because you are shy with other people?

    Yes
    No

Is drinking affecting your reputation?

    Yes
    No

Have you ever felt remorse after drinking?

    Yes
    No

Have you gotten into financial difficulties as a result of drinking?

    Yes
    No

Do you turn to lower companions and an inferior environment when drinking?

    Yes
    No

Does your drinking make you careless of your family's welfare?

    Yes
    No

Has your ambition decreased since drinking?

    Yes
    No

Do you crave a drink at a definite time daily?

    Yes
    No

Do you want a drink the next morning?

    Yes
    No

Does drinking cause you to have difficulty in sleeping?

    Yes
    No

Has your efficiency decreased since drinking?

    Yes
    No

Is drinking jeopardizing your job or business?

    Yes
    No

Do you drink to escape from worries or trouble?

    Yes
    No

Do you drink alone?

    Yes
    No

Have you ever had a complete loss of memory as a result of drinking?

    Yes
    No

Has your physician ever treated you for drinking?

    Yes
    No

Do you drink to build up your self confidence?

    Yes
    No

Have you ever been to a hospital or institution on account of drinking?

    Yes
    No