1. Did you ever lose time from work due to gambling? Yes
No
2. Has gambling ever made your home life unhappy? Yes
No
3. Did gambling affect your reputation? Yes
No
4. Have you every felt remorse after gambling? Yes
No
5. Did you ever gamble to get money in which to pay debts or otherwise solve financial difficulties? Yes
No
6. Did gambling cause a decrease in your ambition or efficiency? Yes
No
7. After losing, did you feel you must return as soon as possible back your losses? Yes
No
8. After a win, did you have a strong urge to return and win more? Yes
No
9. Did you often gamble until your last dollar was gone? Yes
No
10. Did you ever borrow to finance your gambling? Yes
No
11. Have you ever sold anything to finance your gambling? Yes
No
12. Were you reluctant to use "gambling money" for normal expenditures? Yes
No
13. Did gambling make you care less of the welfare of yourself and your family? Yes
No
14. Did you ever gamble longer than planned? Yes
No
15. Have you ever gambled to escape worry or trouble? Yes
No
16. Have you ever committed, or considered committing, and illegal act to finance gambling? Yes
No
17. Did gambling cause you to have difficulty in sleeping? Yes
No
18. Do arguments, disappointments or frustrations create within you an urge to gamble? Yes
No
19. Did you ever have an urge to celebrate good fortune by a few hours of gambling? Yes
No
20. Have you ever considered self-destruction as a result of your gambling?