Alcohol Self Assessment Questionnaire Are you worried you’re addicted to alcohol? Complete our self-assessment form and click on submit. We’ll tell you if you’re likely to have a dependency and how to get you the help you need. Do you ever feel that you need to drink first thing in the mornings?*YesNoDo you sweat or shake if you don’t drink every day?*YesNoDo you crave alcohol or find your concentration is affected by thoughts of drinking?*YesNoDo you use alcohol to escape from your problems or to manage feelings of stress, anxiety, low mood or sleeplessness?*YesNoDo you use alcohol to overcome shyness or to make you feel more confident?*YesNoCan you take alcohol out of your life if you want to?*YesNoHave you ever had a blackout, loss of memory or seizure as a result of your alcohol drinking?*YesNoHave you ever lost a job or faced disciplinary action because of your drinking or drinking behaviours?*YesNoHas alcohol use affected your general health and well-being?*YesNoDo you ever become verbally or physically aggressive when you are under the influence of alcohol?*YesNoHave you ever been arrested or faced charges for any criminal actions when you have been under the influence of alcohol?*YesNoHave you ever sought treatment, help or support for alcohol abuse?*YesNoEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.