Self Questionnaire

Use this questionnaire to evaluate your drinking and/or other drug using behavior.  Please answer the following questions about your own concerns about your drinking/using behavior and about its impact on you.  If you would like to speak with a professional about your concerns, please contact the Addiction Resource Council at 262-524-7921.

Section 1

Please answer the following questions related to your drinking/using behavior:

1. Do you drive while intoxicated/high?

2. Have you or someone else been injured as a result of your drinking/drug using?

3. Are you having problems with work, school, or family as a result of your drinking/drug using?

4. Do you get angry if anyone mentions your drinking/using or expresses concerns about your drinking/using?

5. Have you broken promises because of your drinking/using?

6. Are plans frequently upset, cancelled or delayed because of you?

7. Can you handle more alcohol/other drugs now than when you first began using?

Section 2

Please answer the following questions about your behavior, feelings and beliefs in relation to your drinking/using:

1. Have significant others in your life or you been hurt (either physically or emotionally) by your drinking/using behavior?

2. Are other people in your life ever afraid to be around you when you are drinking/using because of the possibility of verbal or physical abuse?

3. Do you have money problems because of your drinking/using?

4. Do you tell lies to cover up for your drinking/using?

5. Do you blame your behavior on your companions?

6. Does your spouse/significant other make threats, such as "If you don't stop drinking/using, I'll leave you"?

7. Has your spouse/significant other ever helped you to "cover up" for a drinking/using episode by calling your employer, or telling others that you are feeling "sick"?

8. Has your spouse/significant other refused social invitations out of fear or anxiety about you?

9. Does your spouse/significant other think that if you stopped drinking/using, your other problems would be solved?

10. Does your spouse/significant other ever hide alcohol/other drugs from you?