Home
Register
For Clients
For Courts
MDOC Agent Referral
District Court Referral
About
Contact
Call Us
:
(800)-213-ETRS
Wayne County
:
734-462-3096
Oakland County
:
248-399-2600
Skip to main content
Skip to primary sidebar
(800)-213-ETRS
|
Wayne County
:
734-462-3096
|
Oakland County
:
248-399-2600
Home
For Clients
For Courts
About
Contact
Register
The Michigan Alcoholism Screening Test
Patient Name
Date
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 times
24. 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
