Addiction Questionnaire

Do you drink or use to overcome shyness or to feel more confident?

Yes
No

Are you having money troubles because of drinking or using?

Yes
No

Do you ever stay home from work because of drinking or using?

Yes
No

Is drinking or using causing troubles in your family?

Yes
No

Is drinking or using giving you a bad reputation?

Yes
No

Have you lost a job or a business because of drinking or using?

Yes
No

Do you drink or use to escape your problems?

Yes
No

Do you drink or use when you are alone?

Yes
No

Do you have blackouts? (Loss of memory for events that happened or of actions you performed while drinking or using?)

Yes
No

Do you feel remorse after drinking or using?

Yes
No

Do you need to drink at a definite time every day?

Yes
No

Do you drink in the morning?

Yes
No

Have you ever been in a hospital because of drinking or using?

Yes
No

Has a doctor ever treated you for your drinking or using?

Yes
No

Do you drink or use too much at the wrong time?

Yes
No

Do you make promises to yourself or others about your drinking or using?

Yes
No

Do you have to keep on drinking or using once you have started?

Yes
No

Is drinking or using making it hard for you to sleep?

Yes
No

Have you had an accident because of drinking or using?

Yes
No

Do you drink or use to relieve the painfulness of living?

Yes
No

Do you have trouble disposing of cans or bottles?

Yes
No

Are you less particular about people you are with and the places you go when you are drinking or using?

Yes
No

Have you been arrested more than once for drunk driving or driving under the influence of drugs?

Yes
No

Has drinking or using affected your health?

Yes
No

If you answered YES to any of these questions, you may have an alcohol or drug problem.
If you answered YES to ONE of these questions: BE AWARE. You may have or you may develop a problem with alcohol or other drugs.
If you answered YES to TWO or more questions, this indicates you have problems with alcohol and/or drugs and should seek help immediately.

Do you want Lakeside to contact you with more information?

Yes
No

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Phone Number

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Just remember, the staff at Lakeside is here for you offering you support through your journey of recovery. Contact us at any time.

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Substance Abuse Self Assessment Questionnaire

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