DWI Education NDP

Read each question carefully and select the most correct answer.

"*" indicates required fields

Name*
1. Not counting the present DWI arrest, how many times have you been arrested on charges involving alcohol?*
Again, do NOT include the present arrest.
2. Is someone close to you concerned about your drinking?*
3. With whom did you do most of your drinking before this arrest?*
4. Do you believe your drinking may be causing you problems?*
5. Do you want help for a drinking problem?*
6. Do you feel you are a normal drinker?*
7. Have you ever awakened the morning after some drinking the night before and found you could not remember a part of the evening?*
8. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?*
9. Can you stop drinking without a struggle after one or two drinks?*
10. Do you ever feel bad about your drinking?*
11. Do your friends or relatives think you are a normal drinker?*
12. Do you ever try to limit your drinking to certain times of the day or to certain places?*
13. Are you always able to stop drinking when you want to?*
14. Have you ever attended a meeting of Alcoholics Anonymous?*
15. Have you gotten into fights when drinking?*
16. Has drinking ever created problems between you and your wife, husband, parent, or other near relative?*
17. Has your wife, husband, a parent, or other near relative ever gone to anyone for help about your drinking?*
18. Have you ever lost friends because of drinking?*
19. Have you ever gotten into trouble at work because of drinking?*
20. Have you ever lost a job because of drinking?*
21. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?*
22. Do you drink before noon fairly often?*
23. Have you ever been told you have liver trouble? Cirrhosis?*
24. After heavy drinking, have you ever had Delirium Tremens (DT’s) or severe shaking?*
25. After heavy drinking, have you ever heard voices or seen things that weren’t really there?*
26. Have you ever gone to anyone for help about your drinking?*
27. Have you ever been in hospital because of drinking?*
28. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital?*
29. Have you ever been in a hospital to be “dried out” (detoxified) because of drinking?*
30. Have you ever been in jail, even for a few hours, because of behavior where alcohol was involved? Count the present arrest.*