Is your Drinking a Problem
Answers marked with a * are required.
Addiction Screening
  This survey is 100% Confidential. ONLY Dr. Rodman will see your responses and contact information.
 
Below are 4 items that you may agree with or disagree with. Rate your level of agreement with each item, being honest and open with yourself. *
  2 - Agree 1 - Neither Agree or Disagree 0 - Disagree
Have you ever thought you should cut down your drug or alcohol use?
Have you ever felt annoyed when people have commented on your drug or alcohol use?
Have you ever felt guilty or badly about your drug or alcohol use?
Have you ever used drugs or alcohol to ease withdrawal symptoms, to avoid a hangover, or to avoid feeling low after using?
 
 
 
Total your score here: *
 
 
 
Please provide the following information: *
First Name
Email
Age
Gender
 
 
 
Note Your Score... Then Click Finished to display what your score says about your level of Potential for Addiction!
  
 
 
 
 

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