| 01. |
Do you lose time from work
due to drinking? |
Yes |
No |
| 02. |
Is
drinking making your home life
unhappy? |
Yes |
No |
| 03. |
Do you drink because you
are shy with other people? |
Yes |
No |
| 04. |
Is drinking affecting your
reputation? |
Yes |
No |
| 05. |
Have you ever felt remorse
after drinking? |
Yes |
No |
| 06. |
Have you ever got into
financial difficulties as a result of
drinking? |
Yes |
No |
| 07. |
Do you turn to lower
companions and an inferior environment when
drinking? |
Yes |
No |
| 08. |
Does drink make you
careless of your family's welfare? |
Yes |
No |
| 09. |
Has your ambition
decreased since drinking? |
Yes |
No |
| 10. |
Do you crave for a drink
at a definite time daily? |
Yes |
No |
| 11. |
Do you want a drink the
next morning? |
Yes |
No |
| 12. |
Does drinking cause you to
have difficulty in sleeping? |
Yes |
No |
| 13. |
Has your efficiency
decreased since drinking? |
Yes |
No |
| 14. |
Is drinking jeopardizing
your job or business? |
Yes |
No |
| 15. |
Do you drink to escape
from worries or trouble? |
Yes |
No |
| 16. |
Have you ever had a
complete loss of memory as a result of
drinking? |
Yes |
No |
| 17. |
Do you
drink
alone? |
Yes |
No |
| 18. |
Has a physician ever
treated you for drinking? |
Yes |
No |
| 19. |
Do you drink to build up
your self-confidence? |
Yes |
No |
| 20. |
Have you ever been in a
hospital or institution on account of
drinking? |
Yes |
No |