JOHNS HOPKINS UNIVERSITY HOSPITAL SCREENING QUESTIONNAIRE
ARE YOU CHEMICALLY DEPENDENT?
Ask yourself the following questions and answer them as honestly as you can.
- Do you lose time from work due to alcohol/drug usage?
- Is alcohol/drug usage making your home life unhappy?
- Do you drink/use drugs because you are shy with other people?
- Is alcohol/drug usage affecting your reputation?
- Have you ever felt remorse after alcohol/drug usage?
- Have you ever gotten into financial difficulties as a result of alcohol/drug usage?
- Do you turn to lower companions and an inferior environment when drinking/using drugs?
- Does your drinking/drug usage make you careless of your family's welfare?
- Has your ambition decreased since drinking/using drugs?
- Do you crave a drink or other drugs at a definite time daily?
- Do you want a drink or other drugs the next morning?
- Does drinking/drug usage cause you to have difficulty in sleeping?
- Has your efficiency decreased since drinking/using drugs?
- Is drinking/drug usage jeopardizing your job or business?
- Do you drink/use drugs to escape from worries or trouble?
- Do you drink/use drugs alone?
- Have you ever had a complete loss of memory as a result of drinking/using drugs?
- Has your physician ever treated you for drinking/drug usage?
- Do you drink/use drugs to build up your self-confidence?
- Have you ever been to a hospital or institution on account of your drinking/drug usage?
If you have answered YES to any one of the questions, there is a definite warning that you may be chemically dependent.
If you answered YES to any two, the chances are that you are chemically dependent.
If you have answered YES to three or more, you are definitely chemically dependent.
Note: The above test questions are derived from a questionnaire used by Johns Hopkins University Hospital, Baltimore, Maryland in deciding whether or not a patient is alcoholic.
ELLEN L. DONALDSON, M.H.R., LMFT, LADC
330 W. GRAY, #100-6C
NORMAN, OK 73069
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