Symptomology Checklist
1. Do you sometimes accidently drink or use more than you originally intended?
*
YES
NO
Symptomology #
2. Have you ever gone places meaning to not use and ended up using?
*
YES
NO
Symptomology #
3. Do you sometimes drink or use first thing in the morning to help you get the day started?
*
YES
NO
Symptomology #
4. Have you ever had a strong desire to use a drug or alcohol?
*
YES
NO
Symptomology #
5. Have you ever neglected your obligations to your family or friends in order to drink, get high or recover from a hangover?
*
YES
NO
Symptomology #
6. Have you ever felt you should cut down on your use of alcohol or other drugs because they are causing you problems in some area of your life?
*
YES
NO
Symptomology #
7. Are you spending less time on activities with your family now that you did before you started drinking or using?
*
YES
NO
Symptomology #
8. Have you ever used drugs with which you were not familiar and had a bad experience or overdosed?
*
YES
NO
Symptomology #
9. Do you ever get hangovers the day after partying?
*
YES
NO
Symptomology #
10. Does it seem like it takes more alcohol or other drugs to get you high now than it did when you first started?
*
YES
NO
Symptomology #
11. Have you ever experienced nausea, vomiting, diarrhea, or heavy sweating after you have stopped drinking or using for a day or more?
*
YES
NO
Symptomology #
12. Do you find yourself drinking or using sometimes without really wanting to?
*
YES
NO
Symptomology #
13. Have you ever tried switching from one drug or alcoholic beverage to another so you wouldn’t get so “messed up”?
*
YES
NO
Symptomology #
14. Have you gone on a binge and stayed high for longer than 24 hours?
*
YES
NO
Symptomology #
15. Do you find that you keep thinking about the next time you are going to use?
*
YES
NO
Symptomology #
16. Have you ever used alcohol or other drugs at work or school or attended while under the influence?
*
YES
NO
Symptomology #
17. Have you ever been kicked out of your house or gotten into serious fights with family members over your drinking or drug use?
*
YES
NO
Symptomology #
18. Are the people with whom you spend a majority of your time now mostly users of alcohol or other drugs?
*
YES
NO
Symptomology #
19. Have you ever driven a vehicle or operated other types of machinery while under the influence?
*
YES
NO
Symptomology #
20. Do you ever find yourself depressed or confused when you come down from alcohol or drug use?
*
YES
NO
Symptomology #
21. Does it seem like you can drink or use more than most of your friends and still maintain control of yourself?
*
YES
NO
Symptomology #
22. Have you ever felt restless, nervous, irritable, or had trouble sleeping after you quit drinking or using?
*
YES
NO
Symptomology #
23. Is it hard for you to stop drinking or using when there is still some of what you are drinking or using left?
*
YES
NO
Symptomology #
24. Once you start drinking or using do you ever have trouble stopping when you want to?
*
YES
NO
Symptomology #
25. Have you noticed, or has anyone else mentioned to you, that your activities or lifestyle are being impacted in some way by daily drinking or getting high?
*
YES
NO
Symptomology #
26. Do you sometimes think of using after a certain activity or event?
*
YES
NO
Symptomology #
27. Have you ever missed or gotten in trouble at work or school because of your drinking or using?
*
YES
NO
Symptomology #
28. Have any of your family members or friends tried to talk you into stopping or cutting down on your drinking or using?
*
YES
NO
Symptomology #
29. Do you sometimes drink or get high when you are alone?
*
YES
NO
Symptomology #
30. Have you ever gone hunting or engaged in other sports while using?
*
YES
NO
Symptomology #
31. Have you ever done things while you were drinking or getting high that you couldn’t remember later?
*
YES
NO
Symptomology #
32. Have you tried to cut down on the amount you drink or use and found that you were not able to get high when you did?
*
YES
NO
Symptomology #
33. Have you ever tried to stop drinking or getting high and started “feeling” so badly that you went back to drinking or using or have you kept a secret stash?
*
YES
NO
Symptomology #
34. Have you ever promised yourself or someone else that you would quit drinking or using and later used again anyway?
*
YES
NO
Symptomology #
35. Do you sometimes have to spend a lot of time running around from place to place trying to obtain alcohol or other drugs?
*
YES
NO
Symptomology #
36. Have you ever dreamed of using and when you awoke you felt like you had used?
*
YES
NO
Symptomology #
37. Have you ever missed appointments or forgotten about other responsibilities or obligations when you were using?
*
YES
NO
Symptomology #
38. Has drinking or using ever caused serious problems in your relationship with husband/wife/partner/romantic interest?
*
YES
NO
Symptomology #
39. Have you had any close calls or dangerous experiences while drinking or using and later realized that you were very lucky not to have been injured or even killed?
*
YES
NO
Symptomology #
40. Have you ever used alcohol or other drugs against medical advice?
*
YES
NO
Symptomology #
41. Do you sometimes drink or use before or on the way to a party to give you a head start on the action?
*
YES
NO
Symptomology #
42. Do you find that it sometimes helps to drink or use a little in the morning to avoid the shakes or get over a hangover from drinking or using the night before?
*
YES
NO
Symptomology #
Client Name
*
First Name
Last Name
Date
*
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Month
-
Day
Year
Date
Submit
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