Randi Fredricks, Addiction Questionnaire

Addiction Questionnaire

This Addiction Questionnaire is not intended to be a diagnostic tool but instead is meant to give you and I a better idea what is happening to you in terms of addictive behavior.

Answer the questions below to the best of your ability.

Rate your answers as follows:

(1) Sometimes
(2) Often
(3) Never - or I don't know

1. Has your addiction stopped being fun?

1	2	3

2. Do you ever do it alone?

1	2	3

3. Is it hard for you to imagine a life without it?

1	2	3

4. Do you find that your friends are allienated by your addiction?

1	2	3

5. Do you partake in your addiction to avoid dealing with your problems?

1	2	3

6. Do you use your addiction to cope with your feelings?

1	2	3

7. Does your addiction let you live in a privately defined world?

1	2	3

8. Have you ever failed to keep promises you made about cutting down or controlling your addiction?

1	2	3

9. Has your addiction caused problems with memory, concentration, or motivation?

1	2	3

10. When you can't partake in your addiction, do you feel anxious or worried about how to get more?.

1	2	3

11. Do you plan your life around your addiction?

1	2	3

12. Have friends or relatives ever complained that your addiction is damaging your relationship with them?

1	2	3

13. Does your addiction make you careless of your family's welfare?

1	2	3

14. Does your addiction help you because you are shy with other people?

1	2	3

15. Is your addiction affecting your reputation?

1	2	3

16. Does your addiction cause you to have difficulty in sleeping?

1	2	3

17. Is your addiction jeopardizing your job or business?

1	2	3

18. Have you ever had a complete loss of memory as a result of your addiction?

1	2	3

19. Has your physician ever treated you for your addiction?

1	2	3

20. Have you ever been to a hospital or institution on account of your addiction?

1	2	3

Congratulations on completing this questionnaire. Enter your contact information below and I will contact you within the next day to discuss your results and find out if you would like to schedule an appointment.

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Telephone:
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Dr. Randi Fredricks Ph.D. is a Psychotherapist and licensed as a Marriage Family Therapist MFC 47803. Dr. Fredricks is not licensed with the California Medical
Board or the California Bureau of Naturopathic Medicine. © 2012 Randi Fredricks, Marriage and Family Therapist, Inc. All rights reserved. Serving
San Jose, Sunnyvale, Santa Cruz, Palo Alto, Monte Sereno, Los Gatos, Cupertino, Mountain View, Scotts Valley, Campbell, Willow Glen, and Milpitas CA.