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Questionnaire

Does the person show a personality change when drinking or using?	Yes	No
Does the person usually drink or use more than they intended?	Yes	No
Does the person miss planned activities due to drinking or drugs?	Yes	No
Is drinking or drug use jeopardizing the person's job?	Yes	No
Does the person neglect family because of drinking or using?	Yes	No
Has the person violated their moral code due to drinking or using?	Yes	No
Does the person get defensive at suggestions that he/she needs to quit?	Yes	No
Are you afraid to be around the person because of physical/verbal abuse?	Yes	No
Have you been embarrassed by the person's drinking/using?	Yes	No
Have you ever lied to anyone concerning the person's drinking/using?	Yes	No
Are holidays and social functions unpleasant for you?	Yes	No
Do you feel anxious or tense around the person?	Yes	No
Have you ever helped the person to "cover up" for the drinking/using?	Yes	No
Has the person ever been arrested for driving under the influence?	Yes	No
Have you ever found alcohol or drugs that the person has hidden?	Yes	No
Has the person's spiritual life been affected by alcohol or drugs?	Yes	No
Has the person's physical life been affected by alcohol or drugs?	Yes	No
Has the person's emotional life been affected by alcohol or drugs?	Yes	No
Is the person having financial difficulties related to drinking/using?	Yes	No
Would you say that the person denies that he/she has a problem?	Yes	No

IF YOU HAVE ANSWERED FIVE OR MORE WITH YES, INTERVENTION COULD BE CONSIDERED

REMEMBER: CALL EARLY FOR THE BEST RESULTS