
| Do you feel you are a normal drinker? | Yes No |
| Does someone close to you worry about your drinking? | Yes No |
| Do you feel guilty about your drinking? | Yes No |
| Do friends/relatives think you're a normal drinker? | Yes No |
| Can you stop drinking when you want to? | Yes No |
| Have you ever attended an AA meeting? | Yes No |
| Has drinking created problems between you and a loved one/relative? | Yes No |
| Gotten in trouble at work because of drinking? | Yes No |
| Neglected obligations/family/work 2 days in a row because of drinking? | Yes No |
| Gone to anyone for help for your drinking? | Yes No |
| Ever been in a hospital because of drinking? | Yes No |
| Arrested for drunk driving or DUI? | Yes No |
| Arrested for other drunken behavior? | Yes No |

Scoring: Each question answered YES scores 1 point except for questions 1, 4 & 5 which are 1 point for each NO answer.
Five or more positive items suggests alcohol problem.