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?
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