Alcoholism: Assessment and Resources
TeleHealth Lesson #12 Homework Assignment

Name:
E-mail Address: (very important...please include)

Remember..... put your correct name and email address at the top of this form
in order to receive credit for completing this assignment.

---

Directions: The following is an assessment instrument used to identify problem drinkers. Think of someone you know that you think might have a drinking problem. With that person in mind, answer the following questions (lets keep that person anonymous).

---

YES - 0 pts   NO - 2 pts	1. Does this person feel they are a normal drinker?
YES - 1 pts   NO - 0 pts	2. Does this person's family ever worry or complain about their drinking?
YES - 1 pts   NO - 0 pts	3. Does the person ever feel bad about their drinking ?
YES - 0 pts   NO - 2 pts	4. Do friends or relatives think this person is a normal drinker ?
YES - 0 pts   NO - 2 pts	5. Is the person always able to stop drinking when they want to?
YES - 5 pts   NO - 0 pts	6. Has the person ever attended an Alcoholics Anonymous meeting?
YES - 2 pts   NO - 0 pts	7. Has drinking ever created a problem with this person and a girlfriend or boyfriend (or husband or wife)?
YES - 2 pts   NO - 0 pts	8. Has the person ever gotten into trouble at work because of drinking?
YES - 2 pts   NO - 0 pts	9. Has the person ever neglected obligations, his/her family, school and or his/her work because of drinking?
YES - 5 pts   NO - 0 pts	10. Has the person ever gone to anyone for help about his/her drinking?
YES - 5 pts   NO - 0 pts	11. Has the person ever been in a hospital because of his/her drinking?
YES - 2 pts   NO - 0 pts	12. Has the person ever been arrested, even for a few hours, because of behavior associated with drinking?
YES - 5 pts   NO - 0 pts	13. Has the person ever been arrested for drunk driving or driving after drinking?
select here   0 points   1 points   2 points   3 points   4 points   5 points   6 points   7 points   8 points   9 points 10 points 11 points 12 points 13 points 14 points 15 points 16 points 17 points 18 points 19 points 20 points 21 points 22 points 23 points 24 points 25 points 26 points 27 points 28 points 29 points 30 points 31 points 32 points 33 points 34 points 35 points 36 points	Total Number of Points -- (add the number of points in each answer & then select the total from here)

Scoring: A score of three points or less is considered a non alcoholic, four points is suggestive of alcoholism, a score of five points or more indicates alcoholism.

---

Thinking Ahead! Do a little research then answer the following questions:

What resources are available in your community for the following groups:

Alcoholics:	(agency name)
	(service[s] provided)
	(phone number)
Drug Abusers:	(agency name)
	(service[s] provided)
	(phone number)
Children Of Alcoholics:	(agency name)
	(service[s] provided)
	(phone number)

Did You Remember..... to put your correct name and email address at the top of this form in order to receive credit for completing this assignment?



Return To The Main Page

---