Please help us by completing this survey! Your assistance will help us to determine if there are issues affecting our friends and neighbors.

All responses are anonymous and confidential!

What is your age?

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* 2. What is your age?

Have family or friends ever asked that you cut down on drinking?

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* 3. Have family or friends ever asked that you cut down on drinking?

Have family or friends ever asked you to cut down on drug use; including medications or over-the-counter drugs?

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* 4. Have family or friends ever asked you to cut down on drug use; including medications or over-the-counter drugs?

Has a doctor ever suggested that you cut down or quit the use of alcohol?

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* 5. Has a doctor ever suggested that you cut down or quit the use of alcohol?

Has your alcohol consumption increased over the years, perhaps after retirement or the loss of a loved one?

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* 6. Has your alcohol consumption increased over the years, perhaps after retirement or the loss of a loved one?

Has your alcohol or the over-use of medication ever caused physical or emotional problems?

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* 7. Has your alcohol or the over-use of medication ever caused physical or emotional problems?

Have you ever found yourself using alcohol to help you sleep?

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* 8. Have you ever found yourself using alcohol to help you sleep?

Do you ever find yourself changing drinking patterns; for instance, drinking earlier in the day?

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* 9. Do you ever find yourself changing drinking patterns; for instance, drinking earlier in the day?

Have friends or family members ever told you about the things you said or did while you were drinking but you could not remember?

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* 10. Have friends or family members ever told you about the things you said or did while you were drinking but you could not remember?

Have you ever felt guilt or remorse about drinking or use of medications?

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* 11. Have you ever felt guilt or remorse about drinking or use of medications?

Have you ever felt angry or annoyed at someone who criticized your drinking or medication use?

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* 12. Have you ever felt angry or annoyed at someone who criticized your drinking or medication use?

Does alcohol contribute to a lack of interest in social activities, difficulty in staying in touch with family and friends, or affect eating habits, hygiene, or personal appearance? 

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* 13. Does alcohol contribute to a lack of interest in social activities, difficulty in staying in touch with family and friends, or affect eating habits, hygiene, or personal appearance? 

Does alcohol or drug use by your children or grandchildren have a negative impact on you (financially, or in worrying, or in accepting additional responsibilities)?

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* 14. Does alcohol or drug use by your children or grandchildren have a negative impact on you (financially, or in worrying, or in accepting additional responsibilities)?

Are you now a primary caretaker or a child or grandchild because of your child's or grandchild's alcohol or drug use?

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* 15. Are you now a primary caretaker or a child or grandchild because of your child's or grandchild's alcohol or drug use?

Are you being mistreated or hurt by other or financially victimized by friends or relatives, due to their alcohol or drug use?

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* 16. Are you being mistreated or hurt by other or financially victimized by friends or relatives, due to their alcohol or drug use?

Do your leisure activities include some form of gambling as entertainment (trips to a casino, bingo, lottery tickets, etc.)?

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* 17. Do your leisure activities include some form of gambling as entertainment (trips to a casino, bingo, lottery tickets, etc.)?

Have your gambling activities been questioned by family members?

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* 18. Have your gambling activities been questioned by family members?

Do you think you have an alcohol, drug, or gambling problem?

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* 19. Do you think you have an alcohol, drug, or gambling problem?

Describe your quality of life:

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* 20. Describe your quality of life:

If you have a problem, do you know where to get help?

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* 21. If you have a problem, do you know where to get help?

How have alcohol, drugs, or gambling affected you, friends, or family?

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* 22. How have alcohol, drugs, or gambling affected you, friends, or family?

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