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Self Test

This self-test is not intended to be used for the diagnosis or treatment of any medical or emotional condition. We advise you to consult your doctor about any concerns you may have regarding this questionnaire.

The purpose of this survey is to give you some insight into whether or not you may have a problem with Alcohol and/or Drugs.

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information and submit the form. You will receive a confirmation message from us shortly.

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Do you lose time from work due to your drinking or drug use? YES NO
Is your drinking/drug use making your home life unhappy? YES NO
Do you drink or use drugs because you are shy with other people? YES NO
Is drinking or drug use affecting your reputation? YES NO
Have you ever felt remorse after drinking or drug use? YES NO
Have you got into financial difficulties because of your drinking or drug use? YES NO
Do you turn to lower companions and inferior environment when drinking or using drugs? YES NO
Does your drinking or drug use make you careless of your families welfare? YES NO
Has your ambition decreased since drinking or using drugs? YES NO
Do you crave a drink or a drug at a definite time daily? YES NO
Do you want a drink or drug the next morning? YES NO
Does drinking or drug use cause you difficulty in sleeping? YES NO
Has your efficiency decreased since drinking or using drugs? YES NO
Is drinking or drug use jeopardising your job or business? YES NO
Do you drink or use drugs to escape from worries or troubles? YES NO
Do you drink or use drugs alone? YES NO
Have you ever had a complete loss of memory as a result of your drinking or drug use? YES NO
Has your physician ever treated you for drinking or drug use? YES NO
Do you drink or use drugs to build up your self confidence? YES NO
Have you ever been in a hospital or institution as a result of drinking or drug use? YES NO

If you have answered YES to any three of the questions, there is a definite warning that you may be an alcoholic / addict.

If you answered YES to any four of these questions, the chances are that you are an alcoholic / addict.

If you answered YES to five or more of these questions, you are definitely an alcoholic / addict.

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