Alcohol or drug problem?

The questions that follow are about the use of alcohol and other drugs. Please make a note of the scores as you read through it, or print this page then answer the questions. Scoring and interpretation are located at the end of the questionnaire. Questions 1 through 13 should be answered in terms of experiences in the past 6 months.

During the last 6 months...

1. Have you, a friend, or family member used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or other opiates, uppers, downers, hallucinogens, or inhalants) 
Yes / No

2. Have you felt that you use too much alcohol or other drugs? Yes / No

3. Have you tried to cut down or quit drinking or using alcohol or other drugs?
Yes / No

4. Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.)
Yes / No

5. Have you had any health problems? For example, have you:

• Had blackouts or other periods of memory loss?
  Yes / No
• Injured your head after drinking or using drugs? 
  Yes / No
• Had convulsions, delirium tremens ("DTs")? 
  Yes / No
• Had hepatitis or other liver problems?
  Yes / No
• Felt sick, shaky, or depressed when you stopped?
  Yes / No
• Felt "coke bugs" or a crawling feeling under the skin after you stopped using drugs? 
  Yes / No
• Been injured after drinking or using?
  Yes / No
• Used needles to shoot drugs?
  Yes / No

6. Has drinking or other drug use caused problems between you and your family or friends? 
Yes / No

7. Has your drinking or other drug use caused problems at school or at work?
Yes / No

8. Have you been arrested or had other legal problems? (Such as bouncing bad checks, driving while intoxicated, theft,. or drug possession.)
Yes / No

9. Have you lost your temper or gotten into arguments or fights while drinking or using other drugs? 
Yes / No

10. Are you needing to drink or use drugs more and more to get the effect you want? 
Yes / No

11. Do you spend a lot of time thinking about or trying to get alcohol or other drugs?
Yes / No

12. When drinking or using drugs, are you more likely to do something you wouldn't normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone? 
Yes / No

13. Do you feel bad or guilty about your drinking or drug use? 
Yes / No

The next questions are about your lifetime experiences.

14. Have you ever had a drinking or other drug problem? 
Yes / No

15. Have any of your family members ever had a drinking or drug problem?
Yes / No

16. Do you feel that you have a drinking or drug problem now? 
Yes / No

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Add up the scores

Items 1 and 15 are not scored. The following items are scored as yes=1 and no=0:

1 __ 
2 __
3 __
4 __
5 __ (count all the items listed) 
6 __
7 __
8 __
9 __
10 __
11 __
12 __
13 __
14 __
16 __

Total score: _____ Score range: 0-14

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Preliminary Interpretation of responses

Degree of risk for AOD abuse by score

0-1: None to low
2-3: Minimal
4 or more: Moderate to high: possible need for further assessment

If your score is 4 or more you can get help by:

• Talking to the drug and alcohol counselor at the DSHS office.
• Calling Lifeline Connections at (360) 397-8246
• Calling Community Services Northwest at (360) 397-8488