SELF ASSESSMENT TEST
BreakAway Health Corporation
SELF-ASSESSMENT QUESTIONNAIRE
Alcohol and/or drug use can become an addiction, when the user becomes physically and/or psychologically dependent on it. The consequential negative impact of the substance abuse outweighs the benefits.

Is this you? Are you concerned that you are suffering from an addiction to alcohol, illicit drugs such as heroin, cocaine and marijuana, or prescription drugs such as opiates or benzodiazepine? Our self-assessment questionnaire is designed to help you evaluate whether you are addicted to alcohol or drugs.

Be brave and honest when answering the questions - we take your privacy very seriously and do not record the answers; you will be the only one to see the results.

Do you feel the need to drink or use drugs first thing in the morning?

Do friends or family express concerns about your drinking or drug use and behavior?

Do you crave alcohol or drugs, or find your concentration is affected by thoughts of drinking/ using?

Do you use alcohol or drugs to escape from your problems or to manage feelings of stress, anxiety or sleeplessness?

Do you use alcohol or drugs to overcome shyness or to make you feel more confident?

Can you stop drinking or using drugs if you want to?

Have you ever had a blackout, loss of memory or seizure as a result of drinking or using drugs?

Have you ever lost friends or a relationship because of drinking or using drugs?

Has drinking or using drugs affected your general health and well-being?

Have you ever become aggressive under the influence of alcohol or drugs?

Have you ever stolen or sold personal belongings to fund your alcohol or drug use?

Have you ever been arrested when you have been under the influence of alcohol or drugs?

Have you ever sought treatment, help or support for alcohol or drug abuse?



BreakAway Health Corporation

3151 Airway Ave, Suite D-1

Costa Mesa, CA 92626

Phone - (714) 957-8229

Fax - (714) 957-0244

Email - linda@breakawayhealth.com