OK DQ v I have been told I am a heartless, selfish and ungrateful person. 10. When I get angry or upset I yell and throw or break things.

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1 OK DQ v When I get angry or upset I yell and throw or break things. 9. I have been told I am a heartless, selfish and ungrateful person. Instructions This questionnaire measures truthfulness. Do not give false information. Your records may be reviewed to verify the information you provide. The statements in this booklet are numbered. Read each statement carefully and mark your answer sheet accurately. Match the number of the statement with the number on your answer sheet. All statements must be answered. Do not skip any questions. Complete the information at the top of your answer sheet. Do not make any marks on this booklet. Drinking refers to beer, wine and other liquor. Drugs refer to illegal drugs such as marijuana, cocaine, crack, amphetamines, barbiturates or heroin. Section 1 Answer the following statements True or False. If a statement is True put an X under T for True. If 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 have been told I have a drug problem. 4. As a youth I often lied, stole things, skipped school and/or ran away from home. 5. I am a nonviolent person. 6. There are times when I am very unhappy. 7. I often drink more or use more drugs than I intended. 8. I have used drugs (marijuana, crack, cocaine, amphetamines, barbiturates or heroin) more than I should. 11. It bothers me when I am overlooked or ignored by people I know. 12. My drinking is more than just a little or mild problem. 13. Smoking marijuana helps me settle down, relax and feel good. 14. There have been times when I have been jealous or resentful of others. 15. I can handle my own problems and do not want or need help. 16. There are times I get so angry I cannot control myself. 17. When I drink my personality changes and I seem like a different person. 18. There are times when I am really depressed. 19. I have a lot of anger, resentment and hostility towards others. 20. When offered drugs, I may or may not use them. It depends on how I feel at the time. 21. If someone hurts or insults me, I usually try to get even. 22. I was not caught for some of the things I have done that were wrong. 23. I have been told I have a drinking problem. 24. Two or more of the following apply to me (answer true or false on your answer sheet): a. Ignore bills or loan payments b. Boastful, irritable or demanding c. Poor work or employment history d. Lack of sympathy, affection or gratitude e. Sudden mood changes or a violent temper 25. My use of drugs has threatened my happiness and success in life.

2 26. Compared to others my age, I am more destructive or dangerous. 27. There are times when I am concerned that others may not approve of me. 28. Within the last two years, I have had two or more blackouts (memory loses) after drinking. 29. I avoid associating with or being around others because I do not trust many people. 30. I have gone to Narcotics Anonymous (NA) or Cocaine Anonymous (CA) meetings because of my drug use. 31. I have threatened or physically hurt someone. 32. I spend a lot of time getting alcohol and/or drugs, using them or recovering from their effects. 33. There are times when I really worry about my responsibilities and happiness. 34. I am a recovering alcoholic. I have an alcohol-related problem, but do not drink anymore. 35. Two or more of the following apply to me (answer true or false on your answer sheet): a. Evasive or secretive b. Persistent lying or thefts c. Heavy alcohol or drug use d. Unreliable or untrustworthy e. Repeated problems with the law 36. I have tried to cut down or stop using drugs, but I still use them. 37. I can be dangerous when frustrated, insulted or angered. 38. I have been embarrassed or worried about mistakes I have made. 39. People often think I am antisocial because I am unfriendly, sometimes hostile and unsocial or a loner. 40. I do not know why, but I seem to keep getting into trouble with the law. 41. To be honest, I will manipulate or lie to get my way. 42. I have been in a chemical dependency treatment program for my drug problem. 43. There are times when I get very discouraged. 44. In the last year, drinking has been a problem for me. 45. Anything I do is OK as long as I do not get caught. 46. 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. 47. Two or more of the following apply to me (answer true or false on your answer sheet): a. Brutal or violent b. Uncontrollable or cruel c. Explosive or dangerous d. Fighting or argumentative e. Vengeful or carry a grudge 48. I do not always tell the whole truth when asked about my finances or personal life. 49. I have a drinking or alcohol-related problem. 50. It has been difficult for me to keep close, lasting and warm relationships. 51. I have gone to someone for help about my drug-related problem. 52. I have many problems and conflicts with other people. 53. Important social, occupational or recreational activities have been given up or reduced because of my alcohol and/or drug use. 54. There are times when I get frustrated and really angry. 55. My drinking is a serious problem. 56. I wish people would leave me alone and let me deal with my own life and problems. 57. I have used drugs like marijuana, crack, cocaine, amphetamines, barbiturates or heroin within the last year. 58. I have a short temper and get angry quickly.

3 59. My alcohol and/or drug use has resulted in absences from school and/or work, or poor work performance due to hangovers. 60. There have been times when I have had a job but did not want to go to work. 61. Within the last year, my family has been concerned about my drinking. 62. I have neglected my children, household duties or responsibilities because of my alcohol and/or drug use. 63. People tell me I am antisocial because they say many of my ideas would be harmful to others. 64. There have been times I have felt guilty about using drugs. 65. I am often angry and resentful towards others. 66. I have to use more alcohol or drugs to get as high as I did in the past. 67. I have done things when angry or mad that I regret. 68. I have continued my alcohol and/or drug use despite recurrent arguments or fights with family members about my substance use. 69. There are times when I really worry about myself and my future. 70. I need help to overcome my drinking problem. 71. I cannot say it more clearly. I do not want anybody s help. 72. In the last year, using drugs has been a problem for me. 73. I have been arrested for assault or a violent crime. 74. I have been diagnosed as being alcohol and/or drug dependent. 75. There have been times when I have been concerned about my sex life. 76. I have lied to people about my drinking--either minimizing how much I really drink, or hiding the fact that I drink at all. 77. People tell me I am unsociable because I avoid being close to most people. 78. I have a drug abuse or drug-related problem. 79. There have been times when I have been physically cruel to someone and deliberately hurt them. 80. Sometimes I get angry and upset at myself. 81. I have asked for help with my drinking or alcohol-related problem. 82. People say I am a loner, because I choose not to fit in or socialize with most people. 83. I am in treatment for a drug problem. 84. People tell me I have a quick temper and a bad attitude. 85. I continue to use drugs despite family arguments about my drug use. 86. There are times when I am concerned that others may think badly of me. 87. I have been treated (counseling, outpatient or inpatient) for a drinking problem. 88. Most people irritate or annoy me. 89. I am a recovering drug abuser. I have not used drugs for at least a month, but I have a drugrelated problem. 90. People often think my ideas are against society or could be harmful to others. 91. There are times when I am really down, depressed and discouraged. 92. Two or more of the following apply to me (answer true or false on your answer sheet): a. Cold or indifferent b. Lying or manipulative c. Lack of remorse or regret d. Harassing or threatening e. Unsympathetic or uncaring 93. I have been told I am an alcoholic. 94. When I get angry I can be dangerous.

4 95. I get upset when others criticize me. 96. I do a lot of needless lying and conning of others. 97. I often think about revenge and how I can get even. 98. I have attended Alcoholics Anonymous (AA) meetings for help with my drinking. 99. I am concerned about being unsociable or even at times antisocial I am dependent on drugs and may be addicted to them I continue to drink or use drugs even though I am aware of the harmful effects of repeated alcohol and/or drug use I am a violent person I frequently think about death, dying or suicide I will probably get arrested again It has been difficult to answer some of these questions true or false. Section 2 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 106. Exercise/Physical Activity 107. Positive Attitude/Outlook 108. Dissatisfied with Life 109. Good Sense of Humor/Laugh 110. Anxious/Worried/Fearful 111. Depressed/Discouraged 112. Insomnia/Trouble Sleeping 113. Satisfied with Self/Like Self 114. Financially Stable/Responsible 115. Enthusiastic/Involved in Life 116. Tension/Stress/Nervous 117. Fatigued/Tired/Sluggish 118. Directly Deal with Problems 119. Emotionally Upset/Crying 120. Angry/Hostile with Others 121. Lonely/Unhappy 122. Able to Handle Life's Problems 123. Nervous/Unable to Relax 124. Patient/Tolerant/Understanding 125. Can't Make Decisions/Indecisive 126. Work/Job Satisfaction 127. Admit My Errors/Mistakes 128. Bored/Restless/Uninterested 129. Accept Constructive Suggestions 130. Trust My Own Judgment 131. Stomach Problems/Acidity 132. Difficulty with Others/Conflict 133. Adaptable/Adjustable 134. Marital/Family Problems 135. Self-Reliant/Independent 136. Manipulative/Conning/Lying 137. Secretive/Evasive 138. Loss of Control/Explode/Blow-up 139. Unsocial/Dislike Society/Antisocial

5 Section 3 Select the answer to each of the following statements that is accurate for you. Put an X under the number (1, 2, 3 or 4) that applies to you now My repeated alcohol and/or drug use has resulted in: 1. Absences or poor performance at school or work due to substance use or recovery from hangovers 2. My neglecting children and/or household duties and responsibilities 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 My repeated alcohol and/or drug use has resulted in: 1. Substance-related legal problems 2. Alcohol and/or drug-related arrests I have continued alcohol and/or drug use despite persistent or recurrent: 1. Social or interpersonal problems 2. Arguments or fights with family or my significant other about my substance use I have: 1. Had serious physical, social, emotional or mental problems due to my use of alcohol and/or drugs 2. Continued to use alcohol and/or drugs even though I know they cause serious problems for me 145. 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 or drugs that I used to use 146. I have had withdrawal symptoms like trouble sleeping, tremors, sweating, headaches, nausea or vomiting: 1. After reducing alcohol and/or drug use 2. When I stopped heavy alcohol and/or drug use With regard to alcohol or drug use, I: 1. Use alcohol or drugs to avoid withdrawal symptoms 2. Take more alcohol and/or drugs to relieve or reduce withdrawal symptoms When drinking or using drugs I often: 1. Use more (larger amounts) than I intended 2. Use over a longer period than I intended 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 With regard to alcohol and/or drugs, I: 1. Spend a lot of time obtaining or getting alcohol or drugs 2. Spend a lot of time taking or recovering from alcohol or drugs

6 151. I have been high, drunk or have had withdrawal symptoms after using alcohol or drugs: 1. Before or during school, work or important family functions 2. While driving a vehicle (car, truck or machinery) 152. I have: 1. Cut down or stopped doing many of the things I used to do because of alcohol or drugs 2. Spent more time using alcohol or drugs and less time with my family or hobbies 153. How would you describe your drinking? 1. Serious problem 2. Moderate problem 3. Mild or slight problem 4. No problem 154. How much motivation or desire do you have for alcohol rehabilitation, treatment or help? 1. Want help (highly motivated) 2. Undecided (some motivation) 3. Handle it myself (little motivation) 4. No need (not motivated) 155. 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 156. Recovering means having an alcohol or drug problem, but not using or abusing them anymore. I am a recovering: 1. Alcoholic (beer, wine or liquor) 2. Drug abuser (marijuana, crack, cocaine, amphetamines, barbiturates or heroin) 157. How would you describe your drug use? 1. Serious problem 2. Moderate problem 3. Mild or slight problem 4. No problem 158. 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 159. How much motivation or desire do you have for drug rehabilitation, treatment or help? 1. Want help (highly motivated) 2. Undecided (some motivation) 3. Handle it myself (little motivation) 4. No need (not motivated) 160. How would you describe your present situation. I have serious: 1. Family problems 2. Marital or relationship problems (family and relationship problems) 161. I have been arrested for: 1. A violent crime 2. A crime involving force or the threat of force 162. During the last six months, I have been: 1. Dangerous to myself (suicidal) 2. Dangerous to others (homicidal) (suicidal and homicidal) Return this booklet and your answer sheet to the staff. Thank you for your cooperation.

7 Oklahoma DQ V4.04 NAME: ID #: 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. Your age at your first arrest: 2. Your age at your first conviction: 3. Number of felony arrests: 4. Number of times on probation: 5. Number of probation revocations: 6. Number of times on parole: 7. Number of parole revocations: 8. Total number of times arrested: 9. Number of times sentenced to jail: 10. Number of times sentenced to prison: 11. Number of alcohol-related arrests: 12. Number of drug-related arrests: 13. Number of DUI or DWI arrests: 14. Number of months employed in last 12 months: 15. Previous alcohol or drug offense resulting in license revocation? Y N Section 1 Put an X under T for True or put an X under F for False. Do not skip any items. T F T F T F

8 Section 2 Put an X under the number (1, 2, 3, or 4) that describes you best. Use the following scale to select your answers. 1. Rare or Never 3. Often 2. Sometimes 4. Very Often Section 3 Put an X under the number (1, 2, 3, or 4) that is most accurate for you