This short questionnaire is designed to help identify symptoms and warning signs of a current or potential problem with alcohol or other drugs.* Please read each statement, recording the indicated numeric score for your true or false response.
*Please note: “Drug” refers to any mood-altering substance, including prescription medication.
1. My use of alcohol or other drugs has increased over the past year.
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
2. I have attempted to cut down on how much or how often I drink or use other drugs but have not been very consistent.
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
3. I have lied or minimized to family or friends about how much, or how often I drink or use other drugs.
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
4. I drink or use other drugs even when I have planned not to.
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
5. In the last year I have said to myself, or others, “I can quit any time,” or, “I don’t have a problem.”
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
6. On more than one occasion I could not remember some things that happened while I was drinking or using other drugs.
(If answer is true, give yourself 2 points.)
(If answer is false, give yourself 0 points.)
7. On more than one occasion, I have said or done things while using alcohol or other drugs that I deeply regret.
(If answer is true, give yourself 2 points.)
(If answer is false, give yourself 0 points.)
8. My use of alcohol or other drugs has caused tension or problems in at least one of my most important relationships.
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
9. In the last year, I have missed work or school because of alcohol or other drugs.
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
10. I have had accidents or been injured as a result of drinking or drug use.
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
11. I have legal problems related to drinking or drug use.
(If answer is true, give yourself 1 point.)
(If answer is false, give yourself 0 points.)
Results
Total your score. If your score is:
0 points: Based on your responses to the questionnaire you do not appear to have a current problem with substance use. However, if you completed this questionnaire because you are concerned about your use of alcohol or other drugs, you may want to learn more.
1 to 3 points: Your score indicates that you currently are experiencing some of the symptoms associated with substance use. Substance use is a progressive problem with potentially devastating consequences.
4 or more points: Your score indicates that you currently are experiencing many of the symptoms associated with substance use. Substance use is progressive and characterized by repeated harmful consequences.