A/D EVALUATION

 

Name

 

Age

 

Date

 

 

 

1. Has anyone ever suggested you quit or cut back on your drug/alcohol use?

* Yes___ No___

 

2. Has drinking or using affected your relationships and reputation?

* Yes___ No___

 

3. Have you made promises to control your drinking or using and then broken them?

* Yes___ No___

 

4. Have you ever switched to different drinks or drugs or changed your using pattern in an effort to control or reduce your consumption?

* Yes___ No___

 

5. Have you ever gotten into financial, legal, or marital difficulties due to using?

* Yes___ No___

 

6. Have you ever lost time from work because of using or drinking?

* Yes___ No___

 

7. Have you ever sneaked or hidden your use?

* Yes___ No___

 

8. On occasion, do you feel uncomfortable if alcohol or your drug is not available?

* Yes___ No___

 

9. Do you continue drinking or using when friends or family suggest you have had enough?                               

* Yes___ No___

 

10. Have you ever felt guilty or ashamed about your drinking or using or what you did while under the influence?

* Yes___ No___

 

11. Has your efficiency decreased as a result of your drinking or using?

* Yes___ No___

 

12. When using or drinking, do you neglect to eat properly?

* Yes___ No___

 

13. Do you use or drink alone?

* Yes___ No___

 

14. Do you use or drink more than usual when under pressure, angry, or depressed?

* Yes___ No___

 

15. Are you able to drink or use more now without feeling it, compared to when you first started using?

* Yes___ No___

 

16. Have you lost interest in other activities or noticed a decrease in your ambition as a result of your drinking or using?

* Yes___ No___

 

17. Have you had the shakes or tremors following heavy drinking or using or not using for a period of time?

* Yes___ No___

 

18. Do you want to drink or use at a particular time each day?

* Yes___ No___

 

19. Do you go on and off the wagon?

* Yes___ No___

 

20. Is drinking or using jeopardizing your job?

* Yes___ No___

 

If you answer "yes" to one or more of the above questions, it does not necessarily imply a chemical dependency problem, three or four"yes" answers suggest that you should more closely evaluate your drug and or alcohol use. 5 or more you need to consider some form of help Out/Inpatient care or sober living house. The chances of you helping yourself without help from others is very unlikely.

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