DWI Intervention Questionnaire

"*" indicates required fields

Step 1 of 2

Complete this questionnaire before the course begins.

Allow approximately five minutes to complete both pages of the questionnaire, then submit your answers on page two.

Read each question carefully and select the most correct answer.
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.*
Fill out questions 31 - 43 on the next page.