Are You
Dependent?

Questionnaire

Below is a list of the things you should ask yourself to find out if you may have a problem with drugs or alcohol. Please answer the questions honestly and truthfully.

1. Is a family member, friend, co-worker or doctor hinting or even telling you that they think there is a problem?
Yes	No

2. Are your family or friends saying they wish you could be the way you used to be?
Yes	No

3. Have you decided to stop using alcohol or drugs without success?
Yes	No

4. Do you become annoyed or irritated when family or friends try to discuss your alcohol or drug use?
Yes	No

5. Have you ever hidden drugs or alcohol?
Yes	No

6. Do you have a secret emergency supply of alcohol or drugs?
Yes	No

7. Have you ever driven under the influence of alcohol or drugs?
Yes	No

8. Have you ever blacked out while using alcohol or drugs?
Yes	No

9. Have you ever been on a drug or alcohol binge?
Yes	No

10. Have you changed doctors to maintain your prescription supply?
Yes	No

11. Have you received the same prescription from two or more doctors at the same time?
Yes	No

12. Do you use multiple pharmacies to get the drugs you need?
Yes	No

13. Have you ever been turned down for an early refill?
Yes	No

14. Have you ever stolen or forged a prescription?
Yes	No

15. Have you ever endangered yourself or others by buying drugs off the street?
Yes	No

16. Have you ever sold favors for drugs?
Yes	No

17. Have you ever not been able to remember how you got home?
Yes	No

18. Have you felt great remorse or shame over anything you have done while under the influence of drugs or alcohol?
Yes	No

19. Have you told yourself repeatedly this is the last time?
Yes	No

20. Do you cancel or miss important appointments and meetings because of alcohol or drug use?
Yes	No

21. Have others commented about your changing personality?
Yes	No

22. Have you ever been embarrassed by your behavior when under the influence of drugs or alcohol?
Yes	No

23. Have your children ever asked what is wrong with you?
Yes	No

24. Have you lost personal relationships as a result of your drug or alcohol use?
Yes	No

25. Have you ever lost a job as a result of you alcohol or drug use?
Yes	No

26. Have you ever misplaced things and don't know what happened to them?
Yes	No

27. Have you ever hid your drinking or drug use?
Yes	No

28. Do you lie about your alcohol consumption and drug use?
Yes	No

29. Do you refuse to discuss your drug or alcohol use with family or medical professionals?
Yes	No

30. Do you have a professional license at risk if you reveal your drug or alcohol use?
Yes	No

31. Do you ever feel great shame over your use?
Yes	No

32. Is your frequency of alcohol or drug use increasing?
Yes	No

33. Is your tolerance to alcohol or drugs increasing?
Yes	No

34. Is your sense of despair increasing?
Yes	No

35. Do you find it impossible to stop for any prolonged period of time?
Yes	No

---

If you have answered YES to MORE THAN FIVE of these questions
you may need further evaluation from
a licensed physician.

Please contact us at 707-963-4399