1. To build self-confidence, do you ever use drugs or alcohol?
Yes No

2. If you have a problem at home or at school, do you sometimes get high or drink immediately afterward?
Yes No

3. Are you ever absent from school or work because of alcohol or drugs?
Yes No

4. Are you annoyed when people suggest that your drug and alcohol use is excessive. 
Yes No

5. In your opinion, do your friends and/or family abuse substances?
Yes No

6. Do you feel your professional and personal reputation is damaged because of substance abuse?
Yes No

7. After using substances do you feel depressed?
Yes No

8. Do you feel like you are unable to go out on a date without the assistance of drugs or alcohol?
Yes No

9. Has your drug and alcohol use created conflict with the people you live with?
Yes No

10. Do you avoid necessary purchases so that you can continue to have access to drugs or alcohol?
Yes No

11. Do you feel more powerful when you use alcohol or drugs?
Yes No

12.Has your use of substances resulted in the loss of friendships? 
Yes No

13. On average, do you consume more substances that your friends?
Yes No

14. Do your binges end only when you run out of substances?
Yes No

15. Have you ever had blackouts where you couldn't recall the previous evening's events?
Yes No

16. Have you ever been arrested or hospitalized because of substance abuse?
Yes No

17. Do you avoid learning about the medical and social problems associate with substance abuse? 
Yes No

18. Do you feel that you are a substance abuser?
Yes No

19. Does your family have a history of drug or alcohol abuse?
Yes No

20.  Is there a strong likelihood that you have a substance abuse problem? 
Yes No