OK DQ. 11. It bothers me when I am overlooked or ignored by people I know.

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1 OK DQ Instructions We realize this is a difficult time for you. Nevertheless, we need more information so we can better understand your situation. All questions in this questionnaire should be answered. Do not skip any questions. Complete the information on your answer sheet. Do not make any marks on this booklet. Your records may be reviewed to verify the information you provide. Anticipate approximately 30 minutes to complete this questionnaire. You may begin. Section 1 Answer the following questions True or False. When a statement is true, put an X under T for true. When a statement is false, put an X under F for false on your answer sheet. 1. Sometimes I worry about what other people think or say about me. 2. I am concerned about my drinking. 3. I am impulsive in the sense that I usually fail to plan ahead. I do things on the spur of the moment. 4. I have been told I have a drug problem. 5. When I get angry or upset I yell and throw and break things. 6. There are times when I am very unhappy. 7. My drinking has caused family and social problems for me. 8. I have a lot of anger, resentment and hostility toward others. 9. There have been times when I have felt guilty about using drugs. 10. If someone hurts me or insults me, I usually try to get even. 11. It bothers me when I am overlooked or ignored by people I know. 12. Since my adolescence I have disregarded and violated the rights of others (e.g., vandalism, lying, cruelty, causing injuries, stealing) while I ignored or broke many of society s rules or laws, and this continues to some extent today. 13. Within the last year, my family has been concerned about my drinking. 14. People often assume I am unsociable because I avoid being close to most people. 15. In the last year, using drugs has been a problem for me. 16. Compared to others, I am a violent person. 17. I often drink more or use more drugs than I intended. 18. There have been times when I have been jealous or resentful of others. 19. I have been told I have a drinking problem. 20. I have a poor work record and often fail to honor my financial obligations or debts. 21. My use of drugs has threatened my happiness and success in life. 22. There are times I get so angry I cannot control myself. 23. I have a persistent desire to cut down, control or regulate my substance use. 24. There are times when I am really depressed. 25. Two or more of the following apply to me a. Lack of remorse or regret b. Frequent arguments or fights c. Reckless disregard of safety d. Little, if any, guilt or remorse e. Irritable, aggressive and irresponsible 26. In the last year, drinking has been a problem for me. 27. I have violent temper tantrums and often break or smash things.

2 28. Within the last year, I have had persistent urges or cravings for my substance (alcohol/drugs) of choice. 29. There are times when I am concerned that others may not approve of me. 30. I have lied to people about my drinking - either minimizing how much I really drink, or hiding the fact that I drink at all. 31. I do a lot of needless lying and conning of others. 32. When offered drugs, I may or may not use them. It depends on how I feel at the time. 33. I can be dangerous when frustrated, insulted or angered. 34. Important social, occupational or recreational activities have been given up or reduced because of my alcohol and/or drug abuse. 35. There are times when I get very discouraged. 36. Drinking has interfered with my happiness and success in life. 37. People tell me I disregard and violate the rights of others. 38. I have attended Narcotics Anonymous (NA) or Cocaine Anonymous (CA) meetings because of my drug use. 39. I have attended Alcoholics Anonymous (AA) meetings for help with my drinking. 40. Two or more of the following apply to me a. Brutal or violent b. Uncontrollable or cruel c. Explosive or dangerous d. Argumentative or fighting e. Vengeful or carrying a grudge 41. There are times when I really worry about my responsibilities and happiness. 42. I have a drinking or alcohol-related problem. 43. I don t accept or conform to many social rules or laws; consequently I have frequent encounters with authority and the law. 44. I have a drug abuse or drug-related problem. 45. I have many problems or conflicts with other people. 46. I need help to overcome my drinking problem. 47. I continue to drink and/or use drugs even though I am aware this causes or aggravates my physical and/or psychological problems. 48. I do not always tell the whole truth when asked about my finances or personal life. 49. I have asked for help with my drinking or alcohol-related problem. 50. People often think I am antisocial because I am unfriendly, unsocial and a loner. 51. I have been in a chemical dependency treatment program for my drug problem. 52. I have threatened to physically hurt someone. 53. I have a quick temper and get angry quickly. 54. Almost all of my normal daily activities are associated with (or affected by) my substance use. 55. There are times when I get frustrated and really angry. 56. I have been told I am an alcoholic. 57. People say I lie, mislead and con others. 58. I am often angry and resentful towards others. 59. I have done things when angry or mad that I regret. 60. I have been treated (counseling, outpatient or inpatient) for a drinking problem. 61. When frustrated or angered, my emotions interfere with my judgment. 62. My drinking is a serious problem. 63. Two or more of the following apply to me a. Callous unconcern for others b. Impulsive and irresponsible behavior c. Persistent lying or conning of others d. Often late paying bills and loans e. Poor work or employment history

3 64. There are times when I manipulate and lie to get my way or achieve goals that are important to me. 65. There have been times when I have been physically cruel to someone and deliberately hurt them. 66. There are times when I really worry about myself and my future. 67. I am a recovering alcoholic. I have an alcohol-related problem, but do not drink anymore. 68. People tell me I have a quick temper and a bad attitude. 69. I have used drugs (marijuana, crack, cocaine, amphetamines, barbiturates, heroin, etc.) more than I should. 70. Sometimes I get angry and upset at myself. 71. My drinking is more than just a little or minor problem. 72. It is difficult for me to keep close, warm and lasting relationships. 73. Two or more of the following apply to me a. Cold and indifferent b. Lying and manipulative c. Uncaring and unsympathetic d. Aggressive and argumentative e. Unsocial and at times antisocial 74. When I get angry I can be dangerous. 75. There are times when I am concerned that others may think badly of me. 76. I have lied to people about my use of drugs - either minimizing how much I use, or hiding the fact that I use drugs at all. 77. I often think about revenge and how I can get even. 78. There are times when I am really down, depressed and discouraged. 79. I often disregard social norms, rules or laws. 80. I continue to use drugs despite family arguments about my drug use. 81. I get upset when others criticize me. 82. I like aggressive behavior and violence (e.g., boxing, wrestling, violent video games, etc.). 83. I am a recovering drug abuser. I have not used drugs for at least a month, but I have a drug-related problem. 84. I am a violent person. 85. I have done things that were wrong and I was not caught. 86. People say I am a loner or unsocial because I choose not to fit in or socialize with most people. 87. I use and sometimes abuse drugs. 88. I am ashamed of some of the things I have said and done. 89. I am often antisocial. 90. I have a high probability of getting into arguments or fights. 91. I am dependent on drugs and may be addicted to them. 92. I have an explosive and violent temper. 93. I have been offended and hurt by what someone has said about me. 94. I have gone to someone for help about my drug-related problem. 95. I have been embarrassed or worried about mistakes I have made. 96. Most people irritate or annoy me. 97. I am in treatment for a drug problem.

4 Section 2 Select the answer to each of the following statements that is most accurate for you. Put an X under the number (1, 2, 3, or 4) that applies to you. 98. How many different treatment programs for alcohol problems have you been enrolled in? 1. One 2. Two or three 3. Four or more 4. None 99. How many different treatment programs for drug problems have you been enrolled in? 1. One 2. Two or three 3. Four or more 4. None 100. When drinking or using drugs, I often: 1. Use more (larger amounts) than intended. 2. Use over a longer time than I intended How would you describe your temper? 1. A serious problem. 2. A moderate problem. 3. A slight problem. 4. Not a problem I have tried, but I cannot: 1. Reduce, cut down or control my use of alcohol and/or drugs. 2. Stop using alcohol and/or drugs Within the last year I have had intensive urges or cravings for my substance of choice: 1. In settings where I have used the substance. 2. Randomly, at different times and places How much motivation or desire do you have for alcohol rehabilitation, treatment or help? 1. I want help (highly motivated). 2. Undecided (some motivation). 3. I can handle it myself (little motivation). 4. No need (not motivated) My repeated alcohol and/or drug use has resulted in: 1. Absences or poor performance at school or work due to my substance use. 2. My neglecting children and/or household duties and responsibilities How much motivation or desire do you have for drug rehabilitation, treatment or help? 1. I want help (highly motivated) 2. Undecided (some motivation) 3. I can handle it myself (little motivation) 4. No need (no motivation) 107. I have continued my alcohol and/or drug use despite persistent or recurrent: 1. Social and interpersonal problems. 2. Arguments with my family or significant other about my substance abuse I have repeatedly used alcohol and/or drugs: 1. In physically hazardous or dangerous situations like swimming, boating or skiing. 2. Before driving or operating machinery How would you describe your violence proneness or tendencies? 1. A serious problem. 2. A moderate problem. 3. A slight problem. 4. Not a problem I: 1. Have physical and/or psychological problems that were caused by my substance (alcohol/drug) use. 2. Continue to use substances (alcohol/drugs) that aggravate my physical and/or psychological problems.

5 111. I have noticed within the last year: 1. I use a lot more alcohol and/or drugs to get intoxicated or high. 2. I do not get intoxicated or high when I use the same amount of alcohol and/or drugs that I used to I have had withdrawal symptoms like trouble sleeping, tremors, sweating, headaches, nausea, vomiting, etc. 1. After reducing my alcohol and/or drug use. 2. When I stop heavy alcohol and/or drug use How would you describe your drinking? 1. Serious problem. 2. Moderate problem. 3. Mild or slight problem. 4. No problem Recovering means having an alcohol or drug problem, but not using or abusing substances anymore. I am a recovering: 1. Alcoholic. 2. Drug abuser How would you describe your drug use? 1. Serious problem. 2. Moderate problem. 3. Mild or slight problem. 4. No problem Rate your antisocial (unfriendly, unsociable) attitudes or traits on a ten point scale. One represents very sociable and friendly, whereas ten represents antisocial and unfriendly. I rate myself as: 1. Very sociable and friendly (rating 1 or 2). 2. Sociable and talkative (rating 3, 4 or 5). 3. Distant or unapproachable (rating 6, 7 or 8). 4. Antisocial or unfriendly (rating 9 or 10). Section 3 Rate yourself on the next series of statements. Put an X under the number (1, 2, 3, or 4) that applies to you now. Use the following rating scale: 1. Rare or Never 3. Often 2. Sometimes 4. Very Often or Always 117. Positive Attitude/Outlook 118. Dissatisfied with Life 119. Good Sense of Humor/Laugh 120. Anxious/Worried/Fearful 121. Satisfied with Self/Like Self 122. Depressed/Discouraged 123. Angry/Hostile/Resentful 124. Enthusiastic/Involved in Life 125. Directly Deal with Problems 126. Tension/Stress/Pressure 127. Able to Handle Life s Problems 128. Fatigued/Tired/Worn Out 129. Emotionally Upset/Crying 130. Exercise/Physical Activity 131. Lonely/Unhappy/Alone 132. Self-Reliant/Independent 133. Loss of Control/Explode/Blow-up 134. Nervous/Unable To Relax 135. Insomnia/Trouble Sleeping 136. Trust My Own Judgment 137. Patient/Tolerant/Understanding v8.113

6 Oklahoma DQ First Name: Middle Initial: Last Name: Last 4 Digits of SSN: Age: Marital Status: Ethnicity (Race): Sex: Education (Highest Grade Completed): Date of Birth: / / Month Day Year Today s Date: / / Month Day Year Complete the following information. Number (#) refers to the total number in your lifetime. 1. Were you convicted of a crime before the age of 16: YES: NO: 2. Number of times on probation: 3. Number of probation revocations: 4. Total number of times arrested: 5. Total number of times incarcerated: 6. # of assault/violence-related arrests: 7. Number of alcohol-related arrests: 8. Number of drug-related arrests: 9. # of months employed in last 12 months: 10. Previous alcohol or drug offense resulting in license revocation? YES: NO: Section 1 If a statement is True, put an X under T for True. If a statement is False, put an X under F for False. T F T F Continued on other side.

7 Section 1, continued. T F T F Section 2 Select the answer to each of the following statements that is most accurate for you. Put an X under the number (1, 2, 3, or 4) that applies to you Section 2, continued Section 3 Put an X under the number (1, 2, 3 or 4) that describes you best. Use the following rating scale to select your answers. 1= Rare or Never 3= Often 2= Sometimes 4= Very Often or Always v8.113