CLICK HERE For Printable Version Use this Drug and Alcohol Assessment form to help you or your loved one determine if in fact a drug or alcohol problem exists. This is meant to be a guideline and tool to aid in diagnosing the life controlling issue of substance use and abuse. Simply print this page and fill in the answers to get some pretty accurate results.

Take the Drug and Alcohol Assessment Below:

1. Has anyone ever suggested that you quit or cut back on your drug/alcohol use? Yes ____ No ____

  2. Have you made promises to control your drinking or using and then broken them? Yes ____ No ____

  3. Have you ever gotten into financial, legal or marital difficulties due to using or drinking? Yes ___ No ___

  4. Have you ever hidden your use? Yes ______ No ______

  5. Are you uncomfortable if alcohol or your drug of choice is not available? Yes ______No______

  6. Have you ever felt guilty or ashamed about your drinking or using or what you did while under the influence? Yes ______ No ______

  7. Do you use or drink alone? Yes ______ No ______

  8. Do you use or drink more than usual when under pressure, angry or depressed Yes ____ No ______

  9. Have you ever lost interest in other activities or noticed a decrease in ambition because of your drinking and using? Yes ____ No ______

  10. Do you need to use more drugs or alcohol to get the same effect? Yes ____ No ______

  11. Have you had the shakes or tremors after drinking or using? Yes ____ No ______

  12. Have you continued to use despite adverse consequences? Yes ____ No______

  13. Is drinking or using jeopardizing your job or relationships? Yes ____No ______

  If you answered “yes” to one or more of the above questions, it does not necessarily mean that you have a chemical dependency problem, three or more “yes” answers suggest that you should closely evaluate your drug or alcohol use. Chemical dependency is a pervasive disease that has touched the lives of most Americans at some point.

Drug and Alcohol Facts to Know:

  • One out of every 4 families in the United States suffers from alcohol or drug related addiction problems.
  • An estimated 98 million people in this country are addicted or in a relationship with someone who has a problem with alcohol or drugs.
  • 25-40% of all general hospital patients are admitted for a drug or alcohol related problem.
  • 35 Million people are children of alcoholics.
  • Being Chemically Dependent is a brain disease not evidence of a weak individual
  • Only 3-6% of addicted individuals would fit the description of a “skid Row drunk”.
  • Many alcohol/addicts have jobs, homes and families. 45% of alcoholics are in professional or managerial positions, 25% are white collar workers, and 30% are manual laborers.
  • Over half attended college and only 13% have not finished high school.
  • Chemical Dependency truly is an equal opportunity disease.