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ALCOHOL: A Closer Look
(Wine, Beer, Liquor, and Other Alcohol Based Products) |
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At what age did you first become intoxicated? Years old |
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What has been your recent use of alcohol? (Choose the one that is the most accurate)
___ I havent had any alcohol in the past 6 months
___ I drank within the past 2-6 months
___ I drank 1-3 times in the past month
___ I drank 1-2 times a week in the past month
___ I drank 3-6 times a week in the past month
___ I drank daily in the past month |
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Now think back to any 12-month periods when your use of alcohol caused you the most problems. This might be
the past year. Or, it may be any earlier time in your life. |
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Which 12 months do you choose? _________________________________________
What stands out about the time? _________________________________________ |
- DURING THE TIME PERIOD YOU CHOOSE,
WHICH OF THE FOLLOWING DID YOU EXPERIENCE? |
- Needing to drink more in order to get the desired effect even though you are drinking the same amount as before (e.g.
used to feel good from a 6 pack - now it takes a 12 pack, used to be able to drink others under the table now I get intoxicated
with just a few)
Never Sometimes Often Always
1 2 3 4
(circle one)
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Which of the following have you experienced after using or when attempting to not use.
_______ Nausea or Vomiting ________ Anxiety
_______ Sweating, heart racing ________ Seizures
_______ Shakes or tremors ________ Twitching
_______ Insomnia
_______ Hallucinations (seeing, hearing, feeling things that arent really there).
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Drinking more than you planned (e.g., going on binges, stopping at the bar for just one and staying longer than you
planned)
Never Sometimes Often Always
1 2 3
4 |
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A strong desire to cut down or control your drinking or unsuccessful attempts to cut down or control your drinking
(e.g., switching types of alcohol Vodka to Beer, drinking only on weekends, saying "Im only going to drink X amount, "going
to detox or self-help meetings, promising to cut down or quit drinking.
Never Sometimes Often Always
1 2 3
4
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Giving up or reducing important or enjoyable social, occupational or recreational activities because of your drinking
(e.g., not going places where alcohol isnt served, employment problems, not participating in sporting events, clubs, church,
temple, PTA, etc, as much as you used to, going to bars alone, divorce or problems seeing children or grandchildren due to
drinking)
Never Sometimes Often Always
1 2 3
4
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Continuing to drink in spite of physical or psychiatric problems, either caused by drinking or made worse by drinking
(e.g., blackouts, ulcers, high blood pressure, not taking or taking the medications while you are drinking, weight gain/loss,
heart problems, liver or pancreas problem, drinking while pregnant or nursing, lung or throat problems etc)
Never Sometimes Often Always
1 2
3 4 |
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Continued use of alcohol that has interfered with your responsibilities at work, school, home, etc (e.g., missing
appointments/classes, sneaking a drink while the children nap. Calling in sick whenever hangover. Going to work/school while
still drunk, drinking at work/school etc.
Never Sometimes Often Always
1 2
3 4
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Continuing to drink situations which could be physically hazardous (e.g., driving a vehicle, operating machinery while
under the influence.
Never Sometimes Often Always
1 2
3 4
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Legal problems related to your use
(e.g., DUI. Possession, stealing, intent to supply)
Never Sometimes Often Always
1 2
3 4
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Continuing to drink despite problems in your social life and with your relationships (e.g., family/friends expressing
concern about your drug use, arguments about your use, too paranoid to go out).
Never Sometimes Often Always
1 2
3 4
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HOW IMPORTANT IS IT TO YOU NOW TO BE IN "TREATEMENT FOR ALCOHOL PROBLEMS" ?
1__________ 2__________ 3__________ 4__________
Not Important
Very Important
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