Addiction Questionnaire
Over POWERLESSNESS OVER ADDICTION-Symptoms and manifestations
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1. Being busy with acquiring and using, have you neglected your personal hygiene?
Yes   No
2. Are you compelled to use “just a little” before attending a social gathering where people
    important in your life are present?
Yes   No
3. Are you using alcohol/Drugs in spite of it affecting your reputation?
Yes   No
4. Do you borrow money to drink or use drugs?
Yes   No
5. Do you borrow money to use in spite of an accumulated credit balance?
Yes   No
6. Do you turn to inferior company to facilitate using?
Yes   No
7. Do you feel like using before facing a trying situation?
Yes   No
8. Do you feel there is no substitute to intoxication to beat stress?
Yes   No
9. Are you always pre-occupied with the thought of acquiring and using drugs?
Yes   No
10. Do you continue to use in spite of strong feelings of guilt and remorse?
Yes   No
11. Are all your future plans regarding family welfare and success of jobs underlined with
      continued usage?
Yes   No
12. Do you continue using unconcerned with the loss of good friends and dignified people?
Yes   No
13. Do you continue to use even after being berated by your children or juniors or youngsters?
Yes   No
14. Have you traveled long distances or waited for inordinate periods to acquire your substance?
Yes   No
15. Do you prefer excusing yourself from important social engagements to drink away the time?
Yes   No
16. Are you aware of the health hazards caused by the substances you use and enjoy?
Yes   No
17. Are you compelled to use first thing in the morning, and then again and again?
Yes   No
18. Do you think the only remedy to a hangover is another drink?
Yes   No
19. Do you think you can solve your problems better with intoxication?
Yes   No
20. When the substance of your choice is not available, do you desperately seek for a substitute       intoxicant?
Yes   No
21. Do you manipulate and take advantage of your family’s spiritual beliefs to facilitate using?
Yes   No
22. Do you avoid people who advise you against using intoxicants?
Yes   No
23. Have you been admitted to a hospital for detoxification?
Yes   No
24. Do you continue to use in spite of the implied health hazards?
Yes   No
25. Do you think it is better to get high and pass-on that to sit down and discuss or deal with
      an emotional issue?
Yes   No
26. Do you prefer to drink down a domestic problem? (Wife’s needs, school fees, rations etc).
Yes   No
27. Do you repeatedly sacrifice your moral values for the sake of using?
Yes   No
28. Do you prefer to down your disappointments with liquor instead of dealing with it?
Yes   No
29. Have you continued using even after destroying all the peace and happiness of your family?
Yes   No
30. Have you ever been compelled/driven to use against your will?
Yes   No
31. Have you continued using even after bad accidents blackouts and life threatening incidents?
Yes   No
32. Do you feel compelled to use to face an emotional problem confidently?
Yes   No
33. Have you continued to use even though you are aware that endless intoxication is destroying       your ambition and      motivation?
Yes   No
34. Have you continued to use even after disappointing/frustrating experiences with erectile       dysfunction or loss of      libido?
Yes   No
35. Do you feel compelled to use “just a little” before an important interview?
Yes   No
36. Have you cancelled important interviews for the sake of intoxication?
Yes   No
37. Have you covered your job-related disappointments or frustrations by using instead of       discussing it with your      seniors or employers?
Yes   No
38. Do you feel like topping all your excess emotions with intoxication? (Anger, Joy,
      Frustration, Sorrow, Etc)
Yes   No
39. Do you procrastinate instead of timely action and in the meanwhile use?
Yes   No
40. Have you misused your family’s Securities for the sake of using?
Yes   No
41. Have you disposed off any family’s heirlooms to support your addiction?
Yes   No
42. Are you prepared to sacrifice your family’s welfare to continue using?
Yes   No
43. Have you stopped preferring a particular place, brand or atmosphere for your intoxication?
Yes   No
44. Do you continue using even after the normalcy and discipline of your life is disrupted?
Yes   No
45. Are you prepared to jeopardize your job-security for using?
Yes   No
46. Do you continue to use even after badly damaging your health?
Yes   No
47. Have you stopped looking for excuses to use?
Yes   No
48. Do you continue to use even after knowing that your faculties (Body, Mind, Sense organs)
      are deteriorating?
Yes   No
49. Do you not mind resorting to illegal activities for the sake of acquiring Drugs or Liquor?
Yes   No
50. Have you continued using even after acting or reacting in a negative/destructive way
      with people, situations, and      worsening your addiction?
Yes   No
51. Have you found craving present during periods of abstinence?
Yes   No
52. Have you been “driven” to use in spite of yourself?
Yes   No
53. Have you experienced ‘Time –offs’ where everything related to your concerns are wiped
      away and only the       thoughts of acquiring and using are present in the mind?
Yes   No
54. Are most of your reflections, resolutions and guilt-trips done in a emotional state that soon             passes away rather than      in calm, intelligent contemplation?
Yes   No
55. Do you seek a reward or compensation after every good or bad experience?
Yes   No
56. Do you continue to use even after pushing the family to the limits of emotional, financial
      and social tolerance?
Yes   No
57. Do you continue to use even after making a nuisance of yourself repeatedly in public?
Yes   No
58. Have you acted in self-destructive way due to various reasons and then continued using
      without the incident making      a substantial impact on your addiction?
Yes   No  
 
yes: no:
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