1. |
Did you ever lose time from work or school due to gambling? |
<input type="radio" value="1" name="Q1">Yes |
<input type="radio" value="2" name="Q1">No |
2. |
Has gambling ever made your home life unhappy? |
<input type="radio" value="1" name="Q2">Yes |
<input type="radio" value="2" name="Q2">No |
3. |
Did gambling affect your reputation? |
<input type="radio" value="1" name="Q3">Yes |
<input type="radio" value="2" name="Q3">No |
4. |
Have you ever felt remorse after gambling? |
<input type="radio" value="1" name="Q4">Yes |
<input type="radio" value="2" name="Q4">No |
5. |
Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties? |
<input type="radio" value="1" name="Q5">Yes |
<input type="radio" value="2" name="Q5">No |
6. |
Did gambling cause a decrease in your ambition or efficiency? |
<input type="radio" value="1" name="Q6">Yes |
<input type="radio" value="2" name="Q6">No |
7. |
After losing did you feel you must return as soon as possible and win back your losses? |
<input type="radio" value="1" name="Q7">Yes |
<input type="radio" value="2" name="Q7">No |
8. |
After a win did you have a strong urge to return and win more? |
<input type="radio" value="1" name="Q8">Yes |
<input type="radio" value="2" name="Q8">No |
9. |
Did you often gamble until your last dollar was gone? |
<input type="radio" value="1" name="Q9">Yes |
<input type="radio" value="2" name="Q9">No |
10. |
Did you ever borrow to finance your gambling? |
<input type="radio" value="1" name="Q10">Yes |
<input type="radio" value="2" name="Q10">No |
11. |
Have you ever sold anything to finance gambling? |
<input type="radio" value="1" name="Q11">Yes |
<input type="radio" value="2" name="Q11">No |
12. |
Were you reluctant to use "gambling money" for normal expenditures? |
<input type="radio" value="1" name="Q12">Yes |
<input type="radio" value="2" name="Q12">No |
13. |
Did gambling make you careless of the welfare of yourself or your family? |
<input type="radio" value="1" name="Q13">Yes |
<input type="radio" value="2" name="Q13">No |
14. |
Did you ever gamble longer than you had planned? |
<input type="radio" value="1" name="Q14">Yes |
<input type="radio" value="2" name="Q14">No |
15. |
Have you ever gambled to escape worry, trouble, boredom, loneliness, grief or loss? |
<input type="radio" value="1" name="Q15">Yes |
<input type="radio" value="2" name="Q15">No |
16. |
Have you ever committed, or considered committing, an illegal act to finance gambling? |
<input type="radio" value="1" name="Q16">Yes |
<input type="radio" value="2" name="Q16">No |
17. |
Did gambling cause you to have difficulty in sleeping? |
<input type="radio" value="1" name="Q17">Yes |
<input type="radio" value="2" name="Q17">No |
18. |
Do arguments, disappointments or frustrations create within you an urge to gamble? |
<input type="radio" value="1" name="Q18">Yes |
<input type="radio" value="2" name="Q18">No |
19. |
Did you ever have an urge to celebrate any good fortune by a few hours of gambling? |
<input type="radio" value="1" name="Q19">Yes |
<input type="radio" value="2" name="Q19">No |
20. |
Have you ever considered self-destruction or suicide as a result of your gambling? |
<input type="radio" value="1" name="Q20">Yes |
<input type="radio" value="2" name="Q20">No |