1. 
Do I have more than two drinks a day for men/one for women?

2. 
Has my alcohol use been increasing?

3. 
When I drink do I have a hard time stopping?

4. 
Do I have any medical issues?

5. 
Am I taking any medication?

6. 
Have there been repeated consequences from my alcohol use?

7. 
Have I experienced trauma or have a PTSD diagnosis?

8. 
Am using alcohol to change my mood?

9. 
Has my alcohol use negatively affected my loved ones?

10. 
Do I have any mental health concerns?

11. 
Do I use any other non-prescribed mood altering substances?

12. 
Do I have any legal, probationary, or work issues?

13. 
Was I raised in a heavy drinking environment?

14. 
Have I had withdrawals from drinking?

15. 
Do I have elevated liver enzymes?

16. 
Have I experienced blackouts?

17. 
Was my first drink before age 15?

18. 
Will I review my alcohol use with my support system?

19. 
Do I have alcohol-free outlets or hobbies?

20. 
Am I willing to go through a period of abstinence?

21. 
Gender

22. 
Age

*All information provided is confidential