(Used at Johns Hopkins University Hospital, Baltimore, MD, in deciding whether or not a patient is an alcoholic).
Answer YES or NO to the following questions.
1. Do you lose time from work due to drinking?
2. Is drinking making your home life unhappy?
3. Do you drink because you are shy with other people?
4. Is your drinking affecting your reputation?
5. Have you ever felt remorse after drinking?
6. Have you ever got into financial difficulties as a result of drinking?
7. Do you turn to lower companions and an inferior environment when drinking?
8. Does your drinking make you careless of your family’s welfare?
9. Has your ambition decreased since drinking?
10. Do you crave a drink at a definite time?
11. Do you want a drink the next morning?
12. Does drinking cause you to have difficulty in sleeping?
13. Has your efficiency decreased since drinking?
14. Is drinking jeopardizing your job or business?
15. Do you drink to escape from worries or trouble?
16. Do you drink alone?
17. Have you ever had a complete loss of memory as a result of drinking?
18. Has your physician ever treated you for drinking?
19. Do you drink to build up your self-confidence?
20. Have you ever been to a hospital or institution because of drinking?
If you have answered YES to any one of the questions, there is a definite warning that you may be an alcoholic.
If you have answered YES to any two, the chances are that you are an alcoholic.
If you answered YES to three or more, you are definitely an alcoholic.