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 ever felt remorse after gambling?
    YES    NO 

5. Have you ever gambled to get money to pay debts or solve other financial difficulties?
    YES    NO 

6. Has gambling diminished your ambition or ability to do your job?
    YES    NO 

7. After losing, did you feel you must return as soon as possible and win back your losses?
    YES    NO 

8. After a win, did you have a strong urge to return and win more?
    YES    NO 

9. Do you often gamble until your last dollar is gone?
    YES    NO 

10. Do you ever borrow to finance gambling?
    YES    NO 

11. Have you ever sold anything to finance gambling?
    YES    NO 

12. Are you reluctant to use "gambling money" for normal expenditures?
    YES    NO 

13. Does gambling make you careless about the welfare of yourself and your family?
    YES    NO 

14. Did you ever gamble longer than you had planned?
    YES    NO 

15. Have you ever gambled to escape worry or trouble?
    YES    NO 

16. Have you ever committed, or considered committing, an illegal act to finance gambling?
    YES    NO 

17. Do you have trouble sleeping because of gambling?
    YES    NO 

18. Do arguments, disappointments or frustrations create within you an urge to gamble?
    YES    NO 

19. Do you have an urge to celebrate any good fortune by a few hours of gambling?
    YES    NO 

20. Have you ever considered self destruction as a result of your gambling?
    YES    NO