If you have ever wondered if your use of alcohol might be a problem or was becoming a problem, this questionnaire is designed to help you explore your pattern and level of use.
Directions:
Number a sheet of paper from 1-12. Read each question, one at a time, and simply choose one of the responses that fits your circumstance. Each response is weighted from 0-4 as indicated in parentheses. Place the score that appears in the parenthesis at the end of the response you’ve chosen next to the number of the question on your sheet of paper.

ALCOHOL SCREENING INSTRUMENT FOR SELF-ASSESSMENT*

1. How often do you have a drink containing alcohol?

never (0)
monthly or less (1)
two or four times/month (2)
two or three times/week (3)
four or more times/week (4)
2. How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2 (0)
3 or 4 (1)
5 or 6 (2)
7 – 9 (3)
10 or more (4)3. How often do you have six or more drinks on one occasion?

never (0)
less than monthly (1)
monthly (2)
weekly (3)
daily or almost daily (4)4. How often during the last year have you been unable to remember what happened the night before because of drinking?

never (0)
less than monthly (1)
monthly (2)
weekly (3)
daily or almost daily (4)

5. How often during the last year have you found that you were not able to stop drinking once you started?

never (0)
less than monthly (1)
monthly (2)
weekly (3)
daily or almost daily (4)

6. How often during the last year have you failed to do what is normally expected from you because of drinking (e.g., missed deadlines, poor classroom or work attendance, failed committee responsibilities, inconsistent work patterns?)

never (0)
less than monthly (1)
monthly (2)
weekly (3)
daily or almost daily (4)

7. Have you or someone else been injured as a result of your drinking?

no (0)
yes, but not in last year (2)
yes, during last year (4)

8. Has a relative or friend or doctor or other health worker been concerned about your drinking or suggested you cut down?

no (0)
yes, but not in last year (2)
yes, during last year (4)

9. How often in the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

never (0)
less than monthly (1)
monthly (2)
weekly (3)
daily or almost daily (4)

10. How often during the past year have you had feelings of guilt or remorse after drinking?

never (0)
less than monthly (1)
monthly (2)
weekly (3)
daily or almost daily (4)

11. Have people annoyed you by criticizing your drinking?

no (0)
yes, but not in last year (2)
yes, during last year (4)

12. Have you ever felt that you should cut down on your drinking?

no (0)
yes, but not in last year (2)
yes, during last year (4)

Total your score:

1. _____
2. _____
3. _____
4. _____
5. _____
6. _____
7. _____
8. _____
9. _____
10. _____
11. _____
12. _____

Total: _____

Total for questions 9, 10, 11, 12: _____

Please keep in mind that this is not an interactive form. You may check the boxes and print out a copy so as to keep a record of your responses to the questions. However, the computer will not offer a response based on what you check

Scoring

After you have finished, total your individual item scores into one composite score for all 12 questions. Next, total your individual item scores for the last four questions only (#9 – 12).

You should now have two composite scores – one for all twelve questions and one for the last four questions.

Interpretation

A score of 8 or more for all twelve questions indicates that a harmful level of alcohol consumption is likely.

The last four questions (9,10,11,12) are considered a separate “sub-assessment” embedded into the entire self-administered instrument. On only the last four items, a total score of 1 – 2 indicates that you may have a drinking problem. A score of 3 or more indicates there is a significant possibility that you have a problem with alcohol.

If your score exceeds the cut-off values on either instrument, or if answering these questions has raised a concern, you should seek help.

Questions?

Once you have completed the above questionnaire and scored the results, you may find that you would like to speak with someone about your use of alcohol or have a more comprehensive assessment done. This can be arranged, on-campus, with confidentiality. To schedule an appointment, please call the Alcohol and Other Drug Assistance Program at (848) 932-7884.

(*Borrowed from the University of Michigan Faculty & Staff Assistance Program web site. )