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YES |
NO |
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1 |
Do you lose time
from work due to drinking? |
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| 2 |
Is drinking making
your home life unhappy? |
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| 3 |
Do you drink because
you are shy with other people? |
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| 4 |
Is drinking
affecting your reputation? |
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| 5 |
Have you ever felt
remorse after drinking? |
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| 6 |
Have you gotten into
financial difficulties as a result of drinking? |
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| 7 |
Do you turn to lower
companions and an inferior environment when drinking? |
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| 8 |
Does your drinking
make you careless of your family's welfare? |
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| 9 |
Has your ambition
decreased since drinking? |
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| 10 |
Do you crave a drink
at a definite time daily? |
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| 11 |
Do you want a drink
the next morning? |
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| 12 |
Does drinking cause
you to have difficulty in sleeping? |
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| 13 |
Has your efficiency
decreased since drinking? |
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| 14 |
Is drinking
jeopardizing your job or business? |
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| 15 |
Do you drink to
escape from worries or trouble? |
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| 16 |
Do you drink alone? |
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| 17 |
Have you ever had a
complete loss of memory as a result of drinking? |
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| 18 |
Has your physician
ever treated you for drinking? |
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| 19 |
Do you drink to
build up your self-confidence? |
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| 20 |
Have you ever been to
a hospital or institution on account of drinking? |
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