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DWI Education NDP
Brian Knaack
2022-08-11T00:35:33-05:00
DWI Education NDP
Read each question carefully and select the most correct answer.
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*
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Name
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First
Middle Initial
Last
Email
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1. Not counting the present DWI arrest, how many times have you been arrested on charges involving alcohol?
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Again, do NOT include the present arrest.
0 times
1 time
2 or more times
2. Is someone close to you concerned about your drinking?
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Yes
No
3. With whom did you do most of your drinking before this arrest?
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Spouse
Relative(s)
Friend(s)
Strangers
Alone
4. Do you believe your drinking may be causing you problems?
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Yes
No
No, but it used to cause me problems
Not sure
5. Do you want help for a drinking problem?
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Yes
No
Not sure
6. Do you feel you are a normal drinker?
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Yes
No
7. Have you ever awakened the morning after some drinking the night before and found you could not remember a part of the evening?
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Yes
No
8. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking?
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Yes
No
9. Can you stop drinking without a struggle after one or two drinks?
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Yes
No
10. Do you ever feel bad about your drinking?
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Yes
No
11. Do your friends or relatives think you are a normal drinker?
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Yes
No
12. Do you ever try to limit your drinking to certain times of the day or to certain places?
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Yes
No
13. Are you always able to stop drinking when you want to?
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Yes
No
14. Have you ever attended a meeting of Alcoholics Anonymous?
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Yes
No
15. Have you gotten into fights when drinking?
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Yes
No
16. Has drinking ever created problems between you and your wife, husband, parent, or other near relative?
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Yes
No
17. Has your wife, husband, a parent, or other near relative ever gone to anyone for help about your drinking?
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Yes
No
18. Have you ever lost friends because of drinking?
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Yes
No
19. Have you ever gotten into trouble at work because of drinking?
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Yes
No
20. Have you ever lost a job because of drinking?
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Yes
No
21. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?
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Yes
No
22. Do you drink before noon fairly often?
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Yes
No
23. Have you ever been told you have liver trouble? Cirrhosis?
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Yes
No
24. After heavy drinking, have you ever had Delirium Tremens (DT’s) or severe shaking?
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Yes
No
25. After heavy drinking, have you ever heard voices or seen things that weren’t really there?
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Yes
No
26. Have you ever gone to anyone for help about your drinking?
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Yes
No
27. Have you ever been in hospital because of drinking?
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Yes
No
28. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital?
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Yes
No
29. Have you ever been in a hospital to be “dried out” (detoxified) because of drinking?
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Yes
No
30. Have you ever been in jail, even for a few hours, because of behavior where alcohol was involved? Count the present arrest.
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Yes
No
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