1. How often do you have a drink containing alcohol?
NEVER MONTHLY 2 - 4 TIMES 2 - 3 TIMES 4 OR MORE
OR LESS A MONTH A WEEK TIMES A WEEK
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 3 or 4 5 or 6 7 to 9 10 more
3. How often do you have six or more drinks on one occasion?
NEVER LESS THAN MONTHLY WEEKLY DAILY OR
MONTHLY ALMOST DAILY
4. How often during the last year have you found you were not able to stop drinking once you had started?
NEVER LESS THAN MONTHLY WEEKLY DAILY OR
MONTHLY ALMOST DAILY
5. How often during the last year have you failed to do what was normally expected of you, because of your drinking?
S E V E R ITY OF A L C O H O L D E P E N D E N C E Q U E S T IO N N A IR E
____________________ DATE_____________
APPENDIX 5
Please recall a ty p ic a l perio d o f h e a v y d rinking in th e 6 m o n th s b e fo re you s ta rte d tr e a tm e n t.
When was this? Month:_______________________ Year:__________
Please put a tick (>/) to show how often each of the following statements applied to you during this time.
DURING THAT PERIOD OF HEAVY DRINKING:
1. 1 woke up feeling sweaty
NEVER OR ALMOST NEVER □ SOMETIMES □ OFTEN □ NEARLY ALWAYS □
2. My hands shook first thing in the morning □ □ □ □
3. My whole body shook violently first thing in the
morning if 1 didn't have a drink □ □ □ □
4. 1 woke up absolutely drenched in sweat □ □ □ □
5. 1 dreaded waking up in the morning □ □ □ □
6. 1 was frightened of meeting people first thing in
the morning □ □ □ □
7. 1 felt at the edge of despair when 1 awoke □ □ □ □
8. 1 felt very frightened when 1 awoke □ □ □ □
9. 1 liked to have a morning drink □ □ □ □
10. 1 always gulped my first few morning drinks
down as quickly as possible □ □ □ □
11. 1 drank in the morning to get rid of the shakes □ □ □ □
12. 1 had a very strong craving for drink when
1 awoke □ □ □ □
13. 1 drank more than Î4 bottle spirits a day (or 4 pints beer/2 cans strong lager
/ I bottle table wine) □ □ □ □
14. 1 drank more than Î4 bottle spirits a day (or 8 pints beer/4 cans strong lager
/ 2 bottles wine) □ □ □ □
15. 1 drank more than 1 bottle spirits a day (or 15 pints beer/8 cans strong lager
/ 4 bottles wine) □ □ □ □
16. 1 drank more than 2 bottles spirits a day (or 30 pints beer/15 cans strong lager
/ 8 bottles wine) □ □ □ □
(CONTINUED)
Imagine the following situation:
(1 ) You have been COMPLETELY off drink for a FEW WEEKS (2) You then drink VERY HEAVILY for TWO DAYS
How would you feel the morning after those two days of heavy drinking?
THE MORNING AFTER:
17. I would start to sweat 18. My hands would shake 19. My body would shake
20. I would be craving for a drink
NOT QUITE AT ALL SLIGHTLY MODERATELY A LOT
□ □ □ □
□ □ □ □
□ □ □ □
□ □ □ □
A PPEN D IX 6
A.C .Q - Now N u m b e r:... D a te :...
INSTRUCTIONS: Indicate how much you agree or disagree with each of the following statements by placing a tick ( ) along the line between STRONGLY DISAGREE and STRO NG LY AGREE. The closer you place your tick to one end or the other indicates the strength of your disagreement or agreement with the
statement. Please complete every item. W e are interested in how you are thinking or right now as you are filling out the questionnaire.
RIGHT NOW
1. If there was alcohol right here in front of me, it would be hard not to use it.
STRONG LY DISAGREE _ _ STRONG LY AGREE
2. Drinking alcohol would not be pleasant right now.
STRONG LY DISAGREE _ _ STRONGLY AGREE
3. I would feel better if I could drink.
STRONGLY DISAGREE _ STRONG LY AGREE
4. If I had the chance to use alcohol, I think I would drink.
STRO NGLY DISAGREE _ _ STRO NGLY AGREE
5. Drinking would be wonderful.
STRONG LY DISAGREE _ _ STRONGLY AGREE
6. Even if it were possible, I probably wouldn't drink right now.
STRONGLY DISAGREE ___ STRONG LY AGREE
7. Right now, I miss drinking.
STRONGLY DISAGREE _ _ STRO NG LY AGREE
8. I am going to drink as soon as I possibly can.
STRONG LY DISAGREE _ _ STRO NG LY AGREE
9. I would feel less jittery if I used alcohol right now.
STRO NG LY DISAGREE ___ STRONGLY AGREE
RIGHT NOW
11. I have an urge to drink now.
STR O N G LY DISAGREE STRO NGLY AGREE
12
. 13. 14. 15. 16. 17. 18. 19.20
.21
Right now, I am not making any plans to drink.
STRO NG LY DISAGREE _ STRO NG LY AGREE
I would feel more in control of things right now if I could drink.
STRO NG LY DISAGREE _ . _ STRO NG LY AGREE
Drinking would make me feel less jittery.
STR O N G LY DISAGREE _ STRO NG LY AGREE
I could not stop myself from drinking if I had some alcohol here.
STRO NG LY DISAGREE _ STR O N G LY AGREE