The Michigan Alcoholism Screening Test Patient NameDate MM slash DD slash YYYY Instructions: Circle the word "Yes" or "No", which honestly describes your position in regard to each of the questions below. The key to answering the questions is honesty.1. Do you feel you are a normal drinker? (By normal we mean do you drink less than or as much as most other people.) Yes No 2. Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening? Yes No 3. Does your wife, husband, a parent, or other near relative ever worry or complain about your drinking? Yes No 4. Can you stop drinking without a struggle after one or two drinks? Yes No 5. Do you ever feel guilty about your drinking? Yes No 6. Do friends or relatives think you are a normal drinker? Yes No 7. Are you able to stop drinking when you want to? Yes No 8. Have you ever attended a meeting of Alcoholics Anonymous (AA) ? Yes No 9. Have you gotten into physical fights when drinking? Yes No 10. Has your drinking ever created aproblem between you and your significant other, a parent, or any other relative? Yes No 11. Has your wife, husband (or other family members) ever gone to anyone for help about your drinking? Yes No 12. Have you ever lost friends because of drinking? Yes No 13. Have you ever gotten into trouble at work or school because of drinking? Yes No 14. Have you ever lost a job because of drinking? Yes No 15. Have you ever neglected your obligations, your family or your work for two or more days in a row because of you were drinking? Yes No 16. Do you drink before noon fairly often? Yes No 17. Have you ever been told you have liver trouble? Cirrhosis? Yes No 18. After heavy drinking have you ever had Delirium Tremens (DTs') or severe shaking, or heard voices or seen things that really were not there? Yes No 19. Have you ever gone to anyone for help about your drinking? Yes No 20. Have you ever been in a hospital because of drinking? Yes No 21. Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was part of the problem that resulted in hospitalization? Yes No 22. Have you ever been seen at a psychiatric or mental health clinic, or gone to any doctor, social worker, or clergyman for help with an emotional problem, where drinking was part of the problem? Yes No 23. Have you ever been arrested for drunk driving, driving while intoxicated, or driving under the influence of alcoholic beverages? Yes No If YES, how many times24. Have you ever been arrested, or taken into custody even for a few hours, because of other drunk behavior Yes No If YES, how many times Δ
