Alcohol Dependency Quiz
Hidden
Next Steps: Install the Survey Add-On
This form requires the Gravity Forms Survey Add-On. Important: Delete this tip before you publish the form.
Name
(Required)
First
Last
Phone Number
Email
(Required)
1. How often do you find yourself drinking alcohol?
(Required)
I rarely drink.
I drink occasionally, but only socially.
I drink a few times a week.
I drink almost every day.
2. When you drink alcohol, do you tend to drink more than you planned?
(Required)
No, I typically stick to my plan.
Sometimes, but I can stop if I want to.
Often, I end up drinking more than I intended.
Almost every time, I drink far more than planned.
3. Have you ever tried to cut back or stop drinking, but found it difficult?
(Required)
No, I’ve never tried to cut back.
I’ve tried a few times, but it was easy to stop when I wanted to.
I’ve tried several times and struggled to reduce the amount I drink.
Yes, I’ve tried multiple times and haven’t been able to stop.
4. Do you experience cravings or urges to drink alcohol, even when it’s not an appropriate time?
(Required)
Rarely, if ever.
Sometimes, but I can ignore them.
Often, I find myself wanting to drink at inappropriate times.
Almost constantly, I feel the urge to drink.
5. How does alcohol affect your ability to handle responsibilities?
(Required)
It doesn’t affect my responsibilities at all.
I occasionally feel a little distracted, but it’s manageable.
Sometimes, alcohol causes me to neglect responsibilities.
Alcohol has caused significant problems with my responsibilities (work, family, etc.).
6. Have you ever continued drinking even after it led to problems in your relationships or health?
(Required)
No, I stop drinking when I notice problems.
Occasionally, but I quickly recognize the issues and stop.
Yes, I’ve continued drinking even when it caused issues.
I regularly ignore negative consequences and keep drinking.
7. Do you often feel guilty, anxious, or ashamed after drinking?
(Required)
No, I usually feel fine after drinking.
Sometimes, I feel a little guilty but not much.
I often feel guilty or anxious after drinking.
I frequently feel ashamed or regretful about my drinking habits.
8. Has your tolerance for alcohol increased over time (i.e., needing more alcohol to feel the same effect)?
(Required)
No, my tolerance has stayed the same.
It’s increased a little, but it doesn’t feel significant.
Yes, I find that I need to drink more to get the same effect.
I drink much more than I used to just to feel anything at all.
9. Have you experienced physical symptoms when you haven’t been able to drink, such as shaking, sweating, or nausea?
(Required)
No, I’ve never experienced physical withdrawal symptoms.
I’ve felt a little off sometimes, but nothing major.
I’ve experienced mild withdrawal symptoms occasionally.
Yes, I’ve experienced severe withdrawal symptoms when I couldn’t drink.
10. How does alcohol affect your mood or behavior?
(Required)
I feel the same whether I drink or not.
I feel more relaxed or social when I drink.
Alcohol often changes my mood in ways I don’t expect (e.g., making me angry, sad, etc.).
I often feel out of control or aggressive when I drink.
11. Do you find yourself prioritizing alcohol over other important aspects of your life (e.g., family, work, hobbies)?
(Required)
No, I maintain a good balance.
Sometimes, but I try to keep it under control.
Yes, I often put drinking before other responsibilities.
My drinking has taken priority over everything else.
13. Do you drink to cope with stress, sadness, or other negative emotions?
(Required)
No, I don’t typically drink to cope with emotions.
I sometimes drink to numb feelings or escape problems.
I sometimes drink to numb feelings or escape problems.
I frequently drink to cope with negative emotions or stress.
14. Has your alcohol consumption ever caused issues with your physical health, such as liver problems or memory issues?
(Required)
No, my health hasn’t been affected by alcohol.
I’ve had some minor health problems, but nothing major.
Yes, I’ve had some health issues related to alcohol.
Alcohol has caused significant health problems for me.
15. When you think about your future, do you worry about how alcohol might impact your life?
(Required)
No, I don’t see alcohol as a problem for me.
Occasionally, I think about it, but I’m not too concerned.
Yes, I worry about how alcohol could affect my future.
I’m very concerned about the long-term effects of my drinking habits.
Anything else you'd like to tell us?