• NDP - ADAPTED

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please read each question carefully, and then check the most correct answer in the box provided. Check only one box for each question.

  • Is someone close to you concerned about your drinking?
  • With whom did you do most of your drinking before this arrest?
  • Do you believe your drinking may be causing you problems?
  • Do you want help for a drinking problem?
  • Do you feel you are a normal drinker?
  • Have you ever awakened the morning after some drinking the night before and found you could not remember a part of the evening before?
  • Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?
  • Can you stop drinking without a struggle after one or two drinks?
  • Do you ever feel bad about your drinking?
  • Do your friends or relatives think you are a normal drinker?
  • III-D-23
  • 12. Do you ever try to limit your drinking to certain times of the day or to certain places?
  • 13. Are you always able to stop drinking when you want to?
  • 14. Have you ever attended a meeting of Alcoholics Anonymous?
  • 15. Have you gotten into fights when drinking?
  • 16. Has drinking ever created problems between you and your wife, husband, parent, or other near relative?
  • 17. Has your wife, husband, a parent, or other near relative ever gone to anyone for help about your drinking?
  • 18. Have you ever lost friends because of drinking?
  • 19. Have you ever gotten into trouble at work because of drinking?
  • 20. Have you ever lost a job because of drinking?
  • 21. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?
  • 22. Do you drink before noon fairly often?
  • 23. Have you ever been told you have liver trouble? Cirrhosis?
  • 24. After heavy drinking, have you ever had Delirium Tremens (DT's) or severe shaking?
  • III-D-24
  • 25. After neavy drinking, have you ever heard voices or seen things that weren't really there?
  • 26. Have you ever gone to anyone for help about your drinking?
  • 27. Have you ever been in hospital because of drinking?
  • 28. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital?
  • 29. Have you ever been in a hospital to be "dried out" (detoxified) because of drinking?
  • 30. Have you ever been in jail, even for a few hours, because of drunk behavior? (Count the present arrest)
  • III-D-25
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  • Should be Empty: