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1. |
Do you use alcohol or other drugs to build self
confidence? |
|
Yes No
|
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|
2. |
Do you ever drink or get high immediately after you have a
problem at home, school or work? |
|
Yes No
|
|
|
3. |
Have you ever missed work or school due to alcohol or other
drugs? |
|
Yes No
|
|
|
4. |
Does it bother you if someone says that you use too much
alcohol or other drugs? |
|
Yes
No
|
|
|
5. |
Have you started hanging out with a heavy drinking or drug
using crowd? |
|
Yes
No
|
|
|
6. |
Are alcohol and other drugs affecting your reputation? |
|
Yes
No
|
|
|
7. |
Do you feel guilty or bummed out after using alcohol or other
drugs? |
|
Yes
No
|
|
|
8. |
Do you feel more at ease on a date or social event when
drinking or using other drugs? |
|
Yes
No
|
|
|
9. |
Have you gotten into trouble at home, work, or school for
using alcohol or other drugs? |
|
Yes No
|
|
|
10. |
Do you borrow money or "do without" other things
to buy alcohol and other drugs? |
|
Yes No
|
|
|
11. |
Do you feel a sense of power when you use alcohol or other
drugs? |
|
Yes No
|
|
|
12. |
Have you lost friends since you started using alcohol or other
drugs? |
|
Yes No
|
|
|
13. |
Do your friends use less alcohol or other drugs than you do? |
|
Yes
No
|
|
|
14. |
Do you drink or use other drugs until your supply is all gone? |
|
Yes
No
|
|
|
15. |
Do you ever wake up and wonder what happened the night before? |
|
Yes
No
|
|
|
16. |
Have you ever been arrested or hospitalized due to alcohol or
use of illicit drugs? |
|
Yes
No
|
|
|
17. |
Do you "turn off" or avoid studies or lectures about alcohol
or illicit drug use? |
|
Yes No
|
|
|
18. |
Have you ever tried to quit or to cut back using alcohol or
other drugs? |
|
Yes No
|
|
|
19. |
Has there ever been someone in your family with a drinking or
other drug problem? |
|
Yes
No
|
|
|
20. |
Could you have a problem with alcohol or other drugs? |
|
Yes
No
|
|
|
|
|
If you would like your results reviewed, please include your email
address:
|
|
|
Email:
|
|
|
For statistical purposes, please answer the following demographic
questions:
All information kept strictly confidential |
|
|
| Age:
|
Gender:
|
|
|
Income range:
|
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|
|
If you answer "yes" to any three of the above questions, you may be
at risk for developing alcoholism and/or dependence on another drug.
|
|
|
| If you answer "yes" to five of these questions, you should seek
professional help immediately. |
|
|
| Call The Council at (713)942-4100. Someone can be reached 24 hours
a day, seven days a week. Our e-mail address is
help@council-houston.org. |
|
|
| NOTE: This test was adapted from a test
offered by the National Council on Alcoholism and Drug Dependence. It is not
meant to be used to diagnose a problem with alcohol or other drugs. It's
purpose is for identification of a possible problem. Only a physician or
professional clinician should diagnose. |
