Susan Jacob, Ph.D.
(949) 851-5022
1300 Bristol Street North, Ste. 280
Newport Beach, CA 92660
susan@susanjacobphd.com
DRINKING SELF ASSESSMENT
 
Self Assessment: Drinking
 
Do you have a problem with alcohol or other drugs?

 
Ask yourself the following questions and answer them as honestly as you can.

  1.       Do you drink or use to overcome shyness or to feel more confident?
             Yes No

    1. Is drinking or using causing trouble in your family?
      Yes No

    1. Do you drink or use to escape your problems?
      Yes No

    1. Do you drinking or use when you are alone?
      Yes No

    1. Do you feel remorse after drinking or using?
      Yes No

    1. Do you make promises to yourself or other about drinking or using?
      Yes No

    1. Do you drink or use to relieve the painfulness of living?
      Yes No

    1. Do you hide the empties and dispose of them secretly?
      Yes No

    1. Do you plan in advance to “reward” yourself with a little drinking bout after you've worked very hard in the house?
      Yes No

    1. Do you often wonder if anyone knows how often you drink?
      Yes No

    1. Do you feel wittier or more charming when you are drinking?
      Yes No

    1. Do you become defensive when someone mentions your drinking?
      Yes No

    1. Have you ever decided to stop drinking for a week or so, but only lasted for
      a couple of days?
      Yes No

    1. Has your drinking caused trouble at home?
      Yes No

    1. Do you tell yourself you can stop drinking at anytime you want to, even though you keep getting drunk when you don't mean to?
      Yes No

    1. Have you ever missed days of work or school because of drinking?
      Yes No

      If you would like help,
      please call (949) 851-5022

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