1. Have you ever experienced an inability to control your drinking? Have you gotten drunk more than three times in the past year?
   Yes    No
2. Do you use alcohol to escape problems? Do you feel irritable when you're not drinking?
   Yes    No
3. Have you noticed or have others complained about a change in your personality when you drink?
   Yes    No
4. Do you have a high tolerance to alcohol? Do you need increasingly more alcohol to feel an effect?
   Yes    No
5. Have you experienced blackouts or a time when you could not remember what happened while drinking?
   Yes    No
6. Have you had any problems at work or in school because of drinking? Have you had any medical, social or money problems as a result of drinking?
   Yes    No
7. Are your family and friends concerned about your drinking? Do they complain or nag you about your drinking? Are you annoyed by their meddling?
   Yes    No
8. Do you ever feel that you should drink less? Do you feel guilty or sorry about drinking? Do you ever hide your drinking?
   Yes    No
9. Do you ever drink as soon as you wake up so you feel able to handle the day?
   Yes    No
10. Have you lost interest in eating? Have you lost interest in your family and friends? Have you lost interest in your old hobbies?
    Yes    No

Sources