Alcohol Questionnaire

Michigan Alcohol Screening Test

 
Does your spouse, parent, or relative ever worry or complain about your drinking?
 
Yes  
No  
   
   
Do you ever feel guilty about your drinking?
 
Yes  
No  
   
   
Do friends or relatives think you are a normal drinker?
 
Yes  
No  
   
   
Are you able to stop drinking when you want to?
 
Yes  
No  
   
   
Has drinking ever created a problem between you and your wife, husband, a parent, other relative?
 
Yes  
No  
   
   
Have you ever gotten into trouble at work because of drinking?
 
Yes  
No  
   
     
Have you ever neglected your family or your work obligations, for two or more days in a row because of drinking?

Yes  
No  
   
   
Have you ever gone to anyone for help about your drinking?
 
Yes  
No  
   
   
Have you ever been to a hospital because of your drinking?

Yes  
No  
   
   
Have you ever been arrested for drunken driving, driving while intoxicated, or driving under the influence of alcoholic beverage?

Yes  
No  
   
   
Have you ever been arrested, even for a few hours, because of other drunken behavior?

Yes  
No  

Do you feel you are a normal drinker? By normal we mean do you drink less than or as much as most other people do?
 
Yes  
No  
   
 


Scoring

 1 point for each yes answer.

0-1 points = no problem
2 points = Possible Alcoholism
3 points = Probable Alcoholism


Schedule Appointment

Start your new path in life and be
the change today!

Helpful Forms

Click here to view and print
forms for your appointment