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Alcohol Abuse Alcohol Dependence

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					DSM-IV DIAGNOSTIC CHECKLIST                                                                                                                                                                                                                         Name        __________________
                                                                                                                                                                                                                                                     Date
 Alcohol Abuse                                            Symptoms                                                                                           Diagnostic Criteria: Definite diagnosis of abuse is made when one of A is "yes" & both B and C “’yes’
                                                        Yes                                                                                                  No
A1           Missing school/work                           Intoxicated at home                                   Lost time from work                                            A) 1 Recurring failure to meet social, family, work responsibilities
             Use at work or school                         Lost job                                              Other
  2          Driving while intoxicated                     Drinking with activities such                         Drinking when health problems                                       2 Recurrent use when this is physically hazardous.
             Other                                         as boating, skiing                                    aggravated by alcohol
  3          DWI                                           Arrests                                               Unpaid child support
             Domestic disputes                             License suspension                                    Other                                                               3 Recurring legal problems
  4          Blackouts                                     Alcohol related arrests        Drinking causes life problems:
             Guilty about use                              Friends/family express concern     relationship     legal     job                                                         4 Continued use despite negative consequences or
             Arguments about drinking                      Physical health harmed by use      Other                                                                                    recurring problems due to use.
                                                                                                                                                                                B)     These symptoms have occurred repeatedly in a 12 mo. period.
                                                                                                                                                                                C)     Never having met the criteria for Dependence, the
                                                                                                                                                                                       pattern is consistent with a diagnosis of abuse.
 Alcohol Dependence                                      Symptoms                                                                                            Diagnostic Criteria: Definite diagnosis of dependence is made when any three of A and B is “yes.”
  1          Consumed as much as one case beer, 1 gallon wine, 1/5 hard liquor at one time                                                                                      A) 1 Marked tolerance (50% increase) to achieve effect.
             Other                      4+ drinks/sitting                      Less required to achieve intoxication
  2          Morning hand tremor                           Morning nausea                        Drinking before work
             Morning drinking                              Headache                              Hallucinations                                                                      2 Withdrawal symptoms or use to avoid withdrawal symptoms
             Night sweats                                  Use of substitute to self-medicate withdrawal symptoms
             Other
  3          Not a social drinker                          Drink more than intended                              Experiences difficulty cutting down                                 3 Drinking more or for longer periods than intended.                                                              __
             More frequently                               Greater quantity                                      Other
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  4          Guilty about use                              Annoyed with concern of others                        Thoughts of cutting down                      Other                 4 A persistent desire, or one or more unsuccessful efforts to                                                     __
             Relief drinking                               Sees self as problem drinker                          Periods of abstinence                                                 control use.
  5          Daily drinking                                Hidden alcohol                      Drinking alone                                                  Other                 5 Considerable time spent obtaining alcohol, or drinking it, or
             Binge drinking                                Preoccupation with alcohol          Needs drink                                                                             recovering from its effects.                                                                                    __
  6          Lost friends                                  Physical fights or property damage under the influence                                                                    6 Important activities (social, occupational, recreational) given                                                 __
             Arguments about drinking                      Increased isolation                 Other                                                                                   up or reduced because of drinking.
  7          Prior DWI                                     Told drinking harming liver     After drinking:     rowdy/noisy
             Other arrests                                 Told by MD to decrease use          courage/self-confidence                                                               7 Continued drinking despite knowledge of persistent social,                                                      __
             Lost job due to alcohol                        Blackouts                          angry/quarrelsome                                                                       psychological, or physical problems due to use.
             Other                                         Health would be better without etoh
                                                                                                                                                                                B)       The symptoms have occurred repeatedly during a 12 mo. period.           __
                                                                                                                                                                                         The pattern is consistent with a diagnosis of dependence.
   © Project Cork, 1998                                                                                                                                                                  If Substance Dependence: with or          without physiological dependence

				
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