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Data Questionnaire

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Alcohol Dependence Data Questionnaire
INSTRUCTIONS: The following questions cover a wide range of topics to do with drinking. Please read each question carefully but do not think too much about its exact meaning. Think about your MOST RECENT drinking habits and answer each question by checking the MOST APPROPRIATE heading. If you have any difficulties ASK FOR HELP.

QUESTION
NEVER
1
SOMETIMES
2
OFTEN
3
NEARLY
ALWAYS
4
1
Do you rind difficulty in getting the thought of drinking out of your mind?
2
Is getting drunk more important than your next meal?
3
Do you plan your day around when and where you can drink?
4
Do you drink in the morning, afternoon and evening?
5
Do you drink for the effect of alcohol without caring what the drink is
6
Do you drink as much as you want irrespective of what you are doing the next day?
7
Given that many problems might be caused by alcohol do you still drink too much?
8
Do you know that you won't be able to stop drinking once you start
9
Do you try to control your drinking by giving it up completely for days or weeks at a time
10
The morning after a heavy drinking session do you need your first drink to get yourself going
11
The morning after a heavy drinking session do you wake up with a definite shakiness of your hands
12
After a heavy drinking session do you wake up and retch or vomit
13
The morning after a heavy drinking session do you go out of your way to avoid people?
14
After a heavy drinking session do you see frightening things that later you realize were imaginary?
15
Do you go drinking and the next day rind you have forgotten what happened the night before?
  Tally the numbers for each column, then add your final score.

What is the final score from all four columns?

Scoring: The 15 items summed for a total score than can range from 0 to 45. Scale totals are interpreted as follows: 1-9 low dependence, 10-19 medium dependence, and 20 or greater high dependence.

 
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