A. Drinker Types B. Drinking Locations C. Social Situations. D. Other Drugs E. Beverage Preferences F. Effects of Drinking
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1 A. Drinker Types B. Drinking Locations C. Social Situations D. Other Drugs E. Beverage Preferences F. Effects of Drinking G. Other Life Problems H. Treatment Goals TITLE CARDS
2 Non Drinker (Total Abstainer) Occasional Light Social (Nonproblem) Drinker Moderate or Average Social (Nonproblem) Drinker A 1 A 2 A 3\ Frequent or Heavy Social (Nonproblem) Drinker Problem Drinker Alcoholic A 4 A 5 A 6 A. DRINKER TYPES
3 At Home (My own house, apartment, or room) At Work In Other People s Homes B 1 B 2 B 3 Outdoors Private of Social Clubs Restaurants B 4 B 5 B 6 Social Events (such as Weddings, Parties, Dances) Tavern or Bar While Driving B 7 B 8 B 9 B. DRINKING LOCATIONS
4 I Drink Alone I Drink with my Spouse (Husband, Wife, Companion) I Drink with Relatives Other than my Spouse C 1 C 2 C 3 I Drink with a Male Friend or Friends (No Females Present) I Drink with a Female Friend or Friends (No Males Present) I Drink with Friends of Both Sexes C 4 C 5 C 6 I Drink with Strangers (or with People I Meet After I have Started Drinking) I Drink with Business Associates (for Business Purposes) C 7 C 8 C. SOCIAL SITUATIONS
5 Amphetamine (uppers, speed) dextroamphetamine methamphetamine methylphenidate Barbiturates (downers) Tranquilizers (sedatives) Hypnotics (methaqualone, etc.) Cannabis marijuana hashish, THC D 1 D 2 D 3 Cocaine Hallucinogens LSD, DPT psilocybin, etc. Inhalants (sniffing) gasoline glue, paint, etc D 4 D 5 D 6 Opiates heroin methadone Phencyclidine (PCP) angle dust Other Drugs if not mentioned on other cards D 7 D 8 D 9 D. OTHER DRUGS
6 Beer or Ale Brandy Gin E 1 E 2 E 3 Liqueurs (Cordials) Malt Liquor Pure Alcohol or Alcohol in Nonbeverage Form E 4 E 5 E 6 Rum Sparkling Wine Special Fortified Wine (Port, Sherry, Muscatel, Vermouth, etc.) E 7 E 8 E 9 E. BEVERAGE PREFERENCES (1)
7 Tequila Vodka Whiskey (Scotch, Bourbon, Corn, Blended, etc.) E 10 E 11 E 12 Red, Dry Wine Red, Sweet Wine RoséWine E 13 E 14 E 15 White, Dry Wine White, Sweet Wine Other Beverage Containing Alcohol (not Mentioned on the Other Cards) E 16 E 17 E 18 E. BEVERAGE PREFERENCES (2
8 Calm Happy Peaceful F 1a F 2a F 3a Relaxed Unafraid Angry F 4a F 5a F 6b Depressed Frustrated Lonely F 7b F 8b F 9b F. EFFECTS OF DRINKING (1)
9 Sad Afraid Excited F 10b F 11c F 12c Nervous Restless Tense F 13c F 14c F 15c Friendly Outgoing Secure F 16d F 17d F 18d F. EFFECTS OF DRINKING (2)
10 Strong Superior Inferior F 19d F 20d F 21d Insecure Unfriendly Weak F 22e F 23e F 24e Withdrawn F 25e F. EFFECTS OF DRINKING (3)
11 Aggression (Fighting, Anger, Hostility) Boredom Conflicts with the Law (Being Arrested, Drunk, Driving, Police Visits, Lawsuits, etc.) G 1 G 2 G 3 Depression (or negative Self-Concept) Family Problems (Arguments with Spouse or Family Members) Fatigue, Tiredness G 4 G 5 G 6 Financial Problems Health Problems Problems with not Being Assertive (Being Taken Advanatage or, Always Giving in, Can t Express What I Feel, etc.) G 7 G 8 G 9 G. OTHER LIFE PROBLEMS (1)
12 Problems with Eating or Appetite (or Weight Problems) Problems with Memory or Concentration Problems with Sleeping (Insomnia, Early Waking, Nightmares) G 10 G 11 G 12 Problems with Social Contact (Sociability and Meeting People, Loosing Friends, Loneliness) Sexual Problems Suicidal Thoughts G 13 G 14 G 15 Tension or Anxiety Work Problems Other Problems (not Mentioned on the Other Cards) G 16 G 17 G 18 G. OTHER LIFE PROBLEMS (2)
13 I think that total abstinence is the only answer for me, and I want to stop drinking completely. I think that abstinence may be necessary for me, but I am not sure, If I knew that controlled drinking were impossible for me, then I would want to stop drinking completely. I think that total abstinence is not necessary for me, but I would like to reduce my drinking to a light social and nonproblem level. H 1 H 2 H 3 I think that total abstinence is not necessary for me, but I would like to reduce my drinking to a moderate social and nonproblem level. I think that total abstinence is not necessary for me, but I would like to reduce my drinking to a heavy social and nonproblem level. I think that total abstinence is not necessary for me, and I see not need to reduce my drinking. H 4 H 5 H 6 H. TREATMENT GOALS
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Criteria for Probable Diagnosis: 1. Meets criteria for core symptoms of the disorder. 2. Meets all but one, or a minimum of 75% of the remaining criteria required for the diagnosis 3. Evidence of functional
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