This screening questionnaire is designed to help you look at your alcohol or drug use and consider whether this is a behavior in your life that needs some attention. Answer the following questions YES/NO and then score it using the instructions below.

1. Do you use alcohol more than twice a week?

2. On the days when you use alcohol, do you usually have three drinks or more?

3. Do you use mood-altering drugs not prescribed by a physician from time to time?

4. Do you use prescription drugs to change your mood or personality?

5. Do you sometimes use more than the amount prescribed?

6. Do you get intoxicated on alcohol or drugs more than twice a year?

7. When you're not using alcohol or drugs, do you ever put youtself in situations that raise your risk of getting hurt of having problems?

8. Have you ever felt that you should cut down on your drinking or drug use?

9. Have other people ever criticized your drinking or drug use, or been annoyed by it?

10. Have you ever felt bad or guilty about your drinking or drug use?

11. Have you ever done things while you were using alcohol or drugs that you regretted or that made you feel guilty or ashamed?

12. Have you ever used alcohol or drugs first thing in the morning to feel better, or to get rid of a hangover?

13. Have you ever thought that you might have a problem with your drinking or drug use?

14. Have you ever used alcohol or drugs in larger quantities than you intended?

15. Have you ever used alcohol or drugs more often than you intended?

16. Have you ever used alcohol or drugs for longer periods of time than you intended? In other words, have you even not been able to stop when you planned to?

17. Have you ever had a desire to cut down or control your use?

18. Have you ever tried to cut down or control your use?

19. Do you spend a lot of time getting ready to use alcohol or drugs, using or recovering from using?

20. Have you ever failed to meet a major life responsibility because you were intoxicated, hung over, or in withdrawal?

21. Have you given up an work, social, or recreational activities because of alcohol or drug use?

22. Have you had any physical, psychological, or social problems that were caused by, or made worse by, your alcohol or drug use?

23. Have you ever continued to use alcohol or drugs even though you knew they were causing physical, psychological, or social problems, or making those problems worse?

24. Did your tolerance increase after you started to use?

25. Do you ever get physically uncomfortable or sick the day after using alcohol or drugs?

26. Have you ever used alcohol or drugs to keep you from getting sick the next day, or to make a hangover go away?

Step 1: Count how many times you answered "Yes" to any of the questions numbered 1-13

Step 2: Count how many times you answered "Yes" to any of the questions numbered 14-26

 

If you answered "NO" to all of the above questions, you are at low risk of addiction

If you answered "YES" to three or more of questions 1-13 but answered "NO" to questions 14-26, you are at high risk of becoming addicted

If you answered "YES" to more than three of questions 1-13 and answered "YES" to between three and six of questions 14-26, you are probably in the early stages of addiction

If you answered "YES" to more than three of questions 1-13, and answered "YES" to between six and nine of questions 14-26, you are probably in the middle stages of addiction

If you answered "YES" to more than three of questions 1-13, and answered "YES" to more than nine of questions 14-26, you are probably in the late stages of addiction.

If completing this questionnaire has raised your concerns about your alcohol or drug use, please contact Dr. Irina Kerzhnerman to discuss your concerns.