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!

* 2. What is your age?

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

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

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

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

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

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

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

* 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?

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

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

* 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? 

* 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)?

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

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

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

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

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

* 20. Describe your quality of life:

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

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