Alcoholic, Drug Addict, Rehabilitation Services, Drug Rehab at Seabrook House, Alcohol Rehab, Substance Abuse, Drug Addiction, Detox Treatment

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Self-Test

This self-test is not intended to be used for the diagnosis or treatment of any medical or emotional condition. We advise you to consult your doctor about any concerns you may have regarding this questionnaire.

The purpose of this survey is to give you some insight into whether or not you may have a problem with Alcohol and/or Drugs.

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information (optional), and submit the form. You will receive a confirmation message from us shortly.

Do you lose time from work due to your drinking or drug use?	YES	NO
Is your drinking/drug use making your home life unhappy?	YES	NO
Do you drink or drug because you are shy with other people?	YES	NO
Is drinking or drug use affecting your reputation?	YES	NO
Have you ever felt remorse after drinking or drug use?	YES	NO
Have you gotten into financial difficulties because of your drinking or drug use?	YES	NO
Do you turn to lower companions and inferior environment when drinking or using drugs?	YES	NO
Does your drinking or drug use make you careless of your family's welfare?	YES	NO
Has your ambition decreased since drinking or using drugs?	YES	NO
Do you crave a drink or a drug at a definite time daily?	YES	NO
Do you want a drink or drug the next morning?	YES	NO
Does drinking or drug use cause you difficulty in sleeping?	YES	NO
Has your efficiency decreased since drinking or using drugs?	YES	NO
Is drinking or drug use jeopardizing your job or business?	YES	NO
Do you drink or use drugs to escape from worries or troubles?	YES	NO
Do you drink or use drugs alone?	YES	NO
Have you ever had a complete loss of memory as a result of your drinking or drug use?	YES	NO
Has your physician ever treated you for drinking or drug use?	YES	NO
Do you drink or use drugs to build up your self confidence?	YES	NO
Have you ever been in a hospital or institution as a result of drinking or drug use?	YES	NO

If you have answered YES to any one of the questions, there is a definite warning that you may be an alcoholic.

If you answered YES to any two, the chances are that you are an alcoholic.

If you answered YES to three or more, you are definitely an alcoholic.

(The above test questions are used by Johns Hopkins University Hospital, Baltimore MD., In deciding whether or not a patient is alcoholic.)

If you would like some literature sent to you or to be contacted by Seabrook House, please fill out your name and address.

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Thank you for taking the time to answer the questions in our survey.

TRANSITIONAL LIVING FACILITY | 355 CHURCH STREET | WESTFIELD | PENNSYLVANIA 16950 | P | 814.367.2003 | F | 814.367.2016

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