Dr. Neil Cervera of DrNeil.Com DrNeil.Com
A Trauma informed, evidence based Social Work practice.
Serving the Capital District for more than 30 years.
Alcohol/Drug Survey
26 Questions for evaluation. Please answer the questions below, click on either yes, or no.
Please answer all questions.

1.Do you occasionally drink/drug heavily after a disappointment, a quarrel, or when the boss gives you a hard time?
Yes
No


2.When you have trouble or feel under pressure, do you always drink/drug more heavily than usual?
Yes
No


3.Have you noticed that you are able to handle more beer, wine, or liquor than you did when you were first drinking/drugging?
Yes
No


4.Did you ever wake up on the "morning after" and discover that you could not remember part of the evening before, even though your friends tell you that you did not "pass out"?
Yes
No


5.When drinking/drugging with other people, do you try to have a few extra drinks when others will not know it?
Yes
No


6.Are there certain occasions when you feel uncomfortable if alcohol/drugs are not available?
Yes
No


7.Have you recently noticed that when you begin drinking/drugging you are in more of a hurry to get the first drink/drug than you used to be?
Yes
No


8.Do you sometimes feel a little guilty about your drinking/drugging?
Yes
No


9.Are you secretly irritated when your family or friends discuss your drinking/drugging?
Yes
No


10.Have you recently noticed an increase in the frequency of your memory "blackouts"?
Yes
No


11.Do you often find that you wish to continue your use after your friends say they have had enough?
Yes
No


12.Do you usually have a reason for the occasions when you drink/drug heavily?
Yes
No


13.When you are sober, do you often regret things you have done or said while drinking/drugging?
Yes
No


14.Have you often failed to keep the promises you have made to yourself about controlling or cutting down on your drinking/drugging?
Yes
No


15.Have you ever tried to control your drinking/drugging by making a change in jobs, or moving to a new location?
Yes
No


16.Do you try to avoid family or close friends while you are drinking/drugging?
Yes
No


17.Are you having an increasing number of financial and work problems?
Yes
No


18.Do more people seem to be treating you unfairly without good reason?
Yes
No


19.Do you eat very little or irregularly when you are drinking/drugging?
Yes
No


20.Do you sometimes have the "shakes" in the morning and find that it helps to have a little drink/drug?
Yes
No


21.Have you recently noticed that you cannot drink/drug as much as you once did?
Yes
No


22.Do you sometimes stay drunk/high for several days at a time?
Yes
No


23.Do you sometimes feel very depressed and wonder whether life is worth living?
Yes
No


24.Sometimes after periods of drinking/drugging, do you see or hear things that aren't there ?
Yes
No


25.Do you get terribly frightened after you have been drinking/drugging heavily?
Yes
No

26.My drink/drug of choice is/are:






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