1. Do you use alcohol or other drugs to build self-confidence?
Yes No

2. Do you ever drink or get high immediately after you have a problem at home, school, or work?
Yes No

3. Have you ever missed work or school due to alcohol or other drugs?
Yes No

4. Does it bother you if someone says that you use too much alcohol or other drugs?
Yes No

5. Have you started hanging out with a heavy drinking or drug using crowd?
Yes No

6. Are alcohol and other drugs affecting your reputation?
Yes No

7. Do you feel guilty or bummed out after using alcohol or other drugs?
Yes No

8. Do you feel more at ease on a date or social event when drinking or using other drugs?
Yes No

9. Have you gotten into trouble at home, work, or school for using alcohol or other drugs?
Yes No

10. Do you borrow money or "do without" other things to buy alcohol and other drugs?
Yes No

11. Do you feel a sense of power when you use alcohol or other drugs?
Yes No

12. Have you lost friends since you started using alcohol or other drugs?
Yes No

13. Do your friends use less alcohol or other drugs than you do?
Yes No

14. Do you drink or use other drugs until your supply is all gone?
Yes No

15. Do you ever wake up and wonder what happened the night before?
Yes No

16. Have you ever been arrested or hospitalized due to alcohol or use of illicit drugs?
Yes No

17. Do you "turn off" or avoid studies or lectures about alcohol or illicit drug use?
Yes No

18. Have you ever tried to quit or to cut back using alcohol or other drugs?
Yes No

19. Has there ever been someone in your family with a drinking or other drug problem?
Yes No

20. Could you have a problem with alcohol or other drugs?
Yes No