Name *

First Name

Last Name

A. PHYSIOLOGIC RESPONSE

I. Alcohol quickly makes me light-headed, spacey, uncoordinated. It has always affected me this way.

II. Even a little alcohol makes me sick. This has always been true.

III. When drinking, I have lots of energy and perform better.

IV. At first, alcohol exhilarates me; then I may lose control and drink until drunk.

V. In the past, alcohol always gave me a lift, now it just takes away my shakiness and makes me feel normal.

VI. After only a few drinks, I usually feel sedated by alcohol.

VII. I can overcome my depression by drinking alcohol, but afterward the depression seems worse.

VIII. (Women only) I need and use more alcohol premenstrually.

IX. Usually, I can't feel the effect of my first one or two drinks.

X. Now alcohol lifts my depression temporarily. In my earlier drinking years, I did not suffer from depression.

B. FIRST EXPERIENCE

I. I remember the first time I drank alcohol; I liked the feeling it gave me.

II. My first drinking experience was not good; I reacted badly to alcohol.

III. I can't remember my first drinking experience.

IV. From my first taste, alcohol has had no appeal for me.

C. HANGOVERS

I. All my drinking years I have usually felt miserable the morning after heavy alcohol use.

II. I rarely have hangovers.

III. I frequently suffer from depression after a night of heavy drinking.

IV. I never got hangovers in my early years of heavy drinking, but now I do.

V. I don't get hangovers from my habitual light drinking.

VI. I do get uncomfortable even with very little alcohol. This has always been true.

D. PATTERNS

I. I drink six or more eight-ounce glasses of beer a day or the equivalent in wine (six four-ounce glasses) or hard liquor (six drinks, each containing one and one-half ounces of alcohol) and do not get hangovers.

II. I usually can't predict or control how much alcohol I will drink at one time.

III. I may go for days, weeks, or months without alcohol, but when I drink I tend to binge for several days. This has been my usual pattern since I began drinking.

IV. I rarely want more than two or three drinks at one time.

V. I do not drink because I dislike the way even a little alcohol affects me.

VI. I often experience an urge to drink at the end of the work-day following job-related exposure to fumes from gasoline, printer's ink, house paint, hydrocarbons, or formaldehyde.

VII. I recognize that I can regularly drink a lot, need little sleep, have a strong sex drive, and tend to be a compulsive Type-A personality.

VIII. (Women only) I drink quite moderately except before my period, when my need for alcohol seems to increase.

IX. I have never been a heavy drinker, but I notice if I haven't eaten, I can get drunk on one or two drinks.

X. I drink daily (or frequently) to avoid depression.

E. HEREDITY

I. No one on either side of my family has regularly consumed large amounts of alcohol.

II. I have a close maternal and/or paternal relative who drinks (or formerly drank) alcohol in large amounts.

III. I am of Scandinavian, Celtic, Welsh, or Scottish ancestry and have drinking relatives who suffer from depression.

IV. I am adopted and do not know my biological parentage.

V. My family may or may not be teetotalers, but my biological origins are predominantly northern European or native American.

VI. My family is from a southern Mediterranean country.

VII. A close relative is a heavy drinker, but even one or two drinks makes me spacey.

VIII. I am of Oriental descent. My relatives and I become flushed, dizzy, and nauseated from very little alcohol.

F. PERSONALITY EFFECTS

I. My personality and behavior often change markedly when I drink.

II. My personality and behavior now change markedly when I drink. This was not true in my earlier years of drinking.

III. I mellow out and grow sleepy on a few drinks.

IV. I feel revved up and can often party all night when I'm drinking with few or no signs of intoxication.

V. I sometimes get into fights when drinking a lot. This has been true almost from the time I began drinking.

VI. I use alcohol to control anxiety whenever possible.

VII. I can count on alcohol to lift my lifelong depression temporarily.

VIII. My behavior sometimes gets bizarre when I drink.

IX. I dislike drinking alcohol because it physically upsets me; it does not alter my personality.

X. I feel a quick sense of well-being from my first drink or two, but can't handle more than that without feeling spacey and light-headed.

G. TOLERANCE

I. I have always had a high tolerance for alcohol and can drink large amounts without problems.

II. I have been able to increase my tolerance for alcohol markedly over time, handling it supernormally with minimal hangovers.

III. I have no ability to handle a lot of alcohol.

IV. My tolerance for alcohol has gone down recently. It was much higher for many years.

V. I am inconsistent in how much alcohol I can handle. Often I cannot predict or control how much I will drink.