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Name_______ |
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Date_______ |
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Score_______ |
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Points |
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Yes No |
1. |
Do you feel you are a normal drinker? |
2 - |
2. |
Have you ever awakened the morning after some drinking the night before and found
that you could not remember part of the evening before? |
2 - |
3. |
Does your wife, husband or parents ever worry or complain about your drinking? |
1 - |
*4. |
Can you stop drinking without a struggle after one or two drinks? |
- 2 |
5. |
Do you ever feel bad about your drinking? |
1 - |
*6. |
Do friends or relatives think you are a normal drinker? |
- 2 |
7. |
Do you ever try to limit your drinking to certain times of the day or to certain places? |
1 - |
*8. |
Are you always able to stop drinking when you want to? |
- 2 |
9. |
Have you ever attended a meeting of Alcoholics Anonymous AA? |
5 - |
10. |
Have you gotten into fights when drinking? |
1 - |
11. |
Has drinking ever created problems with you and your wife, husband? |
2 - |
12. |
Has your wife, husband or other family member ever gone to anyone for help about your drinking? |
2 - |
13. |
Have you ever lost friends or girlfriends/boyfriends because of your drinking? |
2 - |
14. |
Have you ever gotten into trouble at work because of drinking? |
2 - |
15. |
Have you ever lost a job because of drinking? |
2 - |
16. |
Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking? |
2 - |
17. |
Do you ever drink before noon? |
1 - |
18. |
Have you ever been told you have liver trouble? Cirrhosis? |
2 - |
19. |
Have you ever had delirium tremens DTs, severe shaking, after heavy drinking? |
2 - |
20. |
Have you ever gone to anyone for help about your drinking? |
5 - |
21. |
Have you ever been in a hospital because of your drinking? |
5 - |
22. |
Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was part of the problem? |
2 - |
23. |
Have you ever been seen at a psychiatric or mental health clinic, or gone to a doctor, social worker, or clergyman for help with an emotional problem in which drinking has played a part? |
2 - |
24. |
Have you ever been arrested, even for a few hours, because of drunk behavior? |
2 - |
25. |
Have you ever been arrested for drunk driving or driving after drinking? |
2 - |
Reference: Selzer ML. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry 127(12): 1653-1658, 1971.