To answer this question, ask yourself the following 20 questions and circle either "Yes" or "No". Answer each question as honestly as you can.
| 1 . Do you lose time from work due to drinking? | Yes | No |
| 2 . Is drinking making your home life unhappy? | Yes | No |
| 3 . Do you drink because you are shy with other people? | Yes | No |
| 4 . Is drinking affecting your reputation? | Yes | No |
| 5 . Have you ever felt remorse after drinking? | Yes | No |
| 6 . Have you gotten into financial difficulties as a result of drinking? | Yes | No |
| 7 . Do you turn to lower companions and an inferior environment when drinking? | Yes | No |
| 8 . Does your drinking make you careless of your family's welfare? | Yes | No |
| 9 . Has your ambition decreased since drinking? | Yes | No |
| 10 . Do you crave a drink at a definite time daily? | Yes | No |
| 11 . Do you want a drink the next morning? | Yes | No |
| 12 . Does drinking cause you to have difficulty in sleeping? | Yes | No |
| 13 . Has your efficiency decreased since drinking? | Yes | No |
| 14 . Is drinking jeopardizing your job or business? | Yes | No |
| 15 . Do you drink to escape from worries or trouble? | Yes | No |
| 16 . Do you drink alone? | Yes | No |
| 17 . Have you ever had a complete loss of memory as a result of drinking? | Yes | No |
| 18 . Has your physician ever treated you for drinking? | Yes | No |
| 19 . Do you, drink to buildup your self-confidence? | Yes | No |
| 20 . Have you ever been to a hospital or institution on account of drinking? | Yes | No |