Self Assessment Questionnaire | Malvern Treatment Centers

These questions are not intended to diagnose but rather to increase the awareness about the effects of your drinking or drug use on your life. Your responses will remain 100% anonymous and confidential. If drugs and alcohol have been disrupting your life, schoolwork, career or personal relationships, it may be time to reach out for a helping hand.

Please read the following questions carefully and answer as honestly as you can.

Are you having money troubles because of drinking or using?

Yes

Do you ever stay home from work because of drinking or using?

Yes

Is drinking or using causing trouble in your family?

Yes

Have you lost a job or a business because of drinking or using?

Yes

Do you drink or use to escape your problems?

Yes

Do you have blackouts? (Loss of memory for events that happened or of actions you performed while drinking or using?)

Yes

Have you ever been in a hospital because of drinking or using?

Yes

Has a doctor ever treated you for your drinking or using?

Yes

Do you drink or use too much at the wrong time?

Yes

Do you make promises to yourself or others about your drinking or using?

Yes

Do you have to keep on drinking or using once you have started?

Yes

Have you had an accident because of drinking or using?

Yes

Do you drink or use to relieve the painfulness of living?

Yes

Have you been arrested more than once for drunk driving or driving under the influence of drugs?

Yes

Has drinking or using affected your health?

Yes

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Final Assessment Score*

Substance Abuse Self Assessment Questionnaire