Was there ever a time in your life when you drank too much?

	no
	yes, in my past
	yes, more recent

Has anyone in your family ever said that you are an excessive drinker (e.g., lush, drunk, alcoholic)?

	yes
	no

Have friends, a doctor, a counselor, or anyone else ever said that you drink too much?

	no
	yes

Has alcohol ever caused problems for you (e.g., relationship, job, legal)?

	no
	yes

Did you experiment with alcohol at an early age (12 or under)?

	yes
	no

Check all of the following that has resulted because of drinking or related symptoms (i.e., hangovers):

	missed work or school
	trouble at work or school
	fired or suspended from work or school
	did not take care of children or teens
	did not cook a meal
	did not clean the house when needed
	did not go to the grocery store when needed
	none listed

How often have you driven while intoxicated?

	never
	once
	twice
	three times
	four times
	five times or more

How often have yo been arrested for driving under the influence and/or for disorderly conduct?

	never
	once
	twice
	three times
	four or more

Because of drinking did you or do you have problems or arguments with friends or family?

	no
	yes, but not anymore
	yes, and I drink anyway

Because of drinking did you or do you spend less time with family or friends?

	no
	yes I used to, but not anymore
	yes, and I drink anyway

Have you ever been seperated or divorced due to drinking?

	no
	yes, in part
	yes, main reason

Because of your drinking did you or do you get into physical fights?

	no
	yes
	yes, and I still drink

Because of your drinking did you or do you sometimes get violent (e.g., throw or break objects)?

	no
	yes
	yes and I still drink

Over time did it take much more drinking to get high or the same effects as before?

	no
	yes, in the past
	yes, currently
	yes, past and present

Did you or have you developed a tolerance to alcohol so that the same amount as doesn't have the same effect?

	no
	yes, in past
	yes, currently
	yes, past and present

Do you spend a lot of time recovering from hangovers?

	no
	I don't know
	yes

Have you experienced significant anxiety or depression while drinking?

	no
	unsure
	yes, anxiety
	yes, depression
	yes, both