Alcoholism Testing Form

Do you ever use alcohol to relax or wind down?

YesNoOther

Do you ever use alcohol to cope with your feelings?

YesNoOther

Do you ever use alcohol to fit in with other people?

YesNoOther

Do you ever use alcohol to feel more comfortable during sex?

YesNoOther

Have you ever been late to work, school or important occasions because of alcohol?

YesNoOther

Do you ever hide your drinking or alcohol?

YesNoOther

Have you ever driven a motor vehicle under the influence of alcohol?

YesNoOther

Have you ever been arrested, detained, or ticketed as a result of drinking?

YesNoOther

Have you ever had a terrible hang over?

YesNoOther

Are people questioning or bothering you about your drinking?

YesNoOther

Do you drink every week or day?

YesNoOther

Is drinking a part of special occasions?

YesNoOther

Do you think or talk about drinking?

YesNoOther

Are you a heavy drinker?

YesNoOther

Can you stop drinking when you want to, every time that you want to?

YesNoOther

Do you have any past trauma?

YesNoOther

Do you count on a lot of people for favors?

YesNoOther

Do you ever change your drinking patterns or choice of drinks?

YesNoOther

Are you looking for the best way to manage your drinking?

YesNoOther

Do you ever crave a drink?

YesNoOther

Do most of your "good times" involve alcohol?

YesNoOther

Do you feel panic with the idea of never drinking again?

YesNoOther

Are you afraid to live without alcohol?

YesNoOther

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

example 313-333-3333

By submitting I hereby confirm that the information I have given above is true, and that I will be receiving an email response to my submission and an invitation to meet with a professional regarding the test results.

Signature

Alcoholism Test Form