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ALCOHOL EVALUATION #2

EVALUATION PAGE TWO
52. HAVE YOU EVER FELT THE URGE TO TELL SOMEONE OFF?
53. PICK THE NUMBER THAT BEST REPRESENTS YOUR CURRENT LEGAL SITUATION. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
54. HAVE THERE BEEN TIMES WHEN YOU FELT LIKE DISOBEYING PEOPLE IN POWER EVEN THOUGH YOU KNEW THEY WERE RIGHT?
55. HAS YOUR DRINKING EVER CAUSED PROBLEMS WITH YOUR FAMILY AND/OR FRIENDS?
56. DO YOU FIND IT DIFFICULT TO GET ALONG WITH LOUD-MOUTHED, "BOSSY", OR OBNOXIOUS PEOPLE?
57. DO YOU TRY SOME TYPE OF SOCIAL/STREET DRUG AT LEAST FOUR TIMES A MONTH? DO NOT INCLUDE ALCOHOL.
58. HAS YOUR WIFE/HUSBAND OR CHILDREN EVER BEEN IN COUNSELING REGARDING EMOTIONAL OR BEHAVIORAL PROBLEMS? IF YOU HAVE NEVER BEEN MARRIED, ANSWER "NO".
59. HAS YOUR WIFE/HUSBAND ATTENDED AN ALANON MEETING BECAUSE OF YOUR DRINKING? IF YOU HAVE NEVER BEEN MARRIED OR IF YOU DO NOT KNOW WHAT ALANON IS, ANSWER "NO".
60. HAVE YOU ATTENDED, OR THOUGHT ABOUT ATTENDING, AN A.A. MEETING BECAUSE OF YOUR DRINKING?
61. DO YOU LIKE TO GOSSIP AT TIMES?
62. HAVE YOU EVER FELT THAT YOU WERE PUNISHED WITHOUT CAUSE?
63. PICK THE NUMBER THAT BEST REPRESENTS YOUR FINANCIAL SITUATION AT THIS TIME. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
64. DO YOU FEEL GUILTY ABOUT YOUR USE OF DRUGS OR MEDICATION? DO NOT INCLUDE ALCOHOL.
65. HAVE YOUR FAMILY AND/OR FRIENDS EVER COMPLAINED ABOUT YOUR USE OF DRUGS OR MEDICATION? DO NO INCLUDE ALCOHOL.
66. BEFORE VOTING, DO YOU VERY CAREFULLY INVESTIGATE THE BACKGROUND AND RECORD OF EACH PERSON RUNNING FOR OFFICE?
67. HAVE YOU EVER INTENSELY DISLIKED ANYONE?
68. HAS YOUR WIFE/HUSBAND/FRIEND EVER THREATENED TO LEAVE BECAUSE OF YOUR DRINKING?
69. MORE THAN ONCE, HAVE YOU GOTTEN VIOLENTLY ANGRY WHILE DRINKING?
70. HAVE THERE BEEN TIMES WHEN YOU TOOK ADVANTAGE OF SOMEONE?
71. ON OCCASION, HAVE YOU HAD DOUBTS ABOUT YOUR ABILITY TO SUCCEED IN LIFE?
72. HAVE YOU TRIED SEVERAL TIMES TO STOP DRINKING, BUT ENDED UP DRINKING AGAIN?
73. HAVE THERE BEEN SOME OCCASIONS WHEN YOU FELT LIKE SMASHING THINGS?
74. PICK THE NUMBER THAT BEST REPRESENTS YOUR CURRENT FAMILY LIFE. ENTER 0 IF THIS DOES NOT APPLY TO YOU. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
75. DO YOU SOMETIMES FEEL ANGRY WHEN YOU DON'T GET YOUR OWN WAY?
76. HAVE YOU EVER FOGOTTEN OR OVERLOOKED YOUR DUTIES, YOUR FAMILY, OR YOUR WORK FOR TWO OR MORE DAYS IN A ROW BECAUSE OF YOUR DRINKING?
77. ARE YOU ALWAYS COURTEOUS, EVEN TO PEOPLE WHO ARE DISAGREEABLE?
78. HAVE YOU EXPERIENCED PHYSICAL AND EMOTIONAL AFTER EFFECTS RESULTING FROM HEAVY DRUG USE?
79. DO YOU SOMETIMES TRY TO GET EVEN RATHER THAN FORGIVE AND FORGET?
80. AT LEAST ONCE WHILE DRINKING, HAVE YOU THOUGHT ABOUT KILLING YOURSELF?
81. SOMETIMES DO YOU HAVE TO HIDE THE FACT THAT YOU HAD BEEN DRINKING?
82. DO YOU USUALLY TAKE MEDICATION TO HELP YOURSELF SLEEP AT NIGHT?
83. IF YOU COULD GET INTO A MOVIE WITHOUT PAYING AND BE SURE YOU WERE NOT SEEN, WOULD YOU PROBABLY DO IT?
84. PICK THE NUMBER THAT BEST REPRESENTS YOUR FEELINGS ABOUT YOURSELF IN THE PAST YEAR. VERY WORST 1 2 3 4 5 6 7 8 9 VERY BEST.
85. AFTER A NIGHT OF HEAVY DRINKING, DOES A DRINK THE NEXT MORNING USUALLY HELP GET YOU GOING?
86. AFTER A NIGHT OF HEAVY DRINKING, THE NEXT MORNING DO YOUR HANDS NOTICEABLY SHAKE?
87. DO YOU ALWAYS ADMIT IT WHEN YOU MAKE A MISTAKE?
88. DO YOU ALWAYS PRACTICE WHAT YOU PREACH?
89. HAVE YOU TRIED SEVERAL TIMES TO STOP USING DRUGS, BUT ENDED UP USING AGAIN?
90. TO AVOID EYE STRAIN DURING A LONG TRIP, SHOULD YOU MOVE YOUR EYES ACROSS THE ROAD FREQUENTLY RATHER THAN JUST STARE AT THE ROAD AHEAD OF YOU?
91. HAVE YOU EVER LOST A JOB BECAUSE OF DRINKING?
92. HAS A DOCTOR OR HEALTH PROFESSIONAL EVER TOLD YOU TO STOP DRINKING?
93. WHEN DRIVING NEAR HOMES, SHOULD YOU WATCH OUT FOR CHILDREN DARTING INTO THE STREETS?
94. IS IT SOMETIMES HARD FOR YOU TO GO ON WITH YOUR WORK IF YOU ARE NOT ENCOURAGED?
95. FROM THE LIST BELOW, ENTER THE NUMBER OF THE ITEM THAT YOU USED OR TRIED MOST OFTEN DURING THE PAST THREE YEARS.
96. WHEN WAS THE LAST TIME THAT YOU USED THIS DRUG (THE ITEM SELECTED IN QUESTION 95)? ENTER 0 IF YOU ENTERED 0 FOR QUESTION 95.
97. FROM THE LIST SHOWN AT QUESTION 95, ENTER THE NUMBER OF THE ITEM THAT YOU USED SECOND MOST OFTEN DURING THE PAST THREE YEARS.
98. WHEN WAS THE LAST TIME THAT YOU USED THIS DRUG (THE ITEM YOU SELECTED IN QUESTION 97)? ENTER 0 IF YOU ENTERED 0 FOR QUESTION 97).
INDICATE THE NUMBER OF TIMES YOU HAVE BEEN ARRESTED FOR AN ALCOHOL/DRUG RELATED OFFENSE.
HOW MANY TIMES HAVE YOU BEEN IN AN IN-PATIENT (HOSPITAL, ETC.) TREATMENT PROGRAM FOR ALCOHOL AND/OR DRUGS?
HOW MANY TIMES HAVE YOU BEEN IN AN INTENSIVE OUTPATIENT (IOP) PROGRAM?
HOW MANY TIMES HAVE YOU BEEN IN SUPPORTIVE OUTPATIENT (SOP) TREATMENT PROGRAM?
YOUR FULL NAME
YOUR MAILING ADRESS INCLUDING THE ZIP CODE
SPN#
YOUR CAUSE NUMBER
YOUR DATE OF BIRTH
CELL PHONE NUMBER
PROBATION OFFICER'S NAME AND FAX NUMBER
THE DATE YOU COMPLETED THE EVALUATION
PLEASE STATE THE CURRENT E-MAIL THAT YOU WANT THE SUMMARY LETTER OF YOUR ALCOHOL AND DRUG EVALUATION SENT TO:
THE TIME YOU COMPLETED THE EVALUATION.
THANK YOU FOR USING THE ONLINE EVALUATION. WITHIN 24 HOURS, MRS. GREGORY WILL SUBMIT YOUR ANSWERS TO ADE, INC. AND GET THE REPORT. IF YOU HAVE NOT HEARD FROM MRS. GREGORY IN 24 HOURS, PLEASE CALL 832-257-4550 OR 832-257-5996.
YOUR CURRENT CHARGE: