| Analyzed Test |
| Name (First & Last):* | |
| Phone:* | |
| Email Address:* | |
| Home Address:* | |
| City:* | |
| State:* | |
| Zip Code:* | |
| Gambled to escape problems, to relieve feeling helpless, guilt, or anxiety. |
|
| Little or no interest in doing things. |
|
| Feeling down, depressed, or hopeless. |
|
| Committed illegal acts such as theft, forgery, or embezzement to finance gambling. |
|
| Trouble falling asleep, staying asleep, or sleeping too much. |
|
| Jepordized or lost a significant relationship, job/educational/career opportunity because of gambling. |
|
| Feeling tired or having little energy. |
|
| Relied on others for money to relieve a desperate gambling financial situation. |
|
| Poor appetite or overeating. |
|
| Gambling after losing money to get even. |
|
| Feeling bad about myself, feeling that I am a failure, or feeling that I have let myself down. |
|
| Felt restless or irrtable when attempting to cut down or stop gambling. |
|
| Preoccupied with gambling. |
|
| Moving or speaking so slowly that other people could have noticed. Or being so fidgety or restless that I have been around a lot. |
|
| Had to gamble increasing amount of money to achieve desired excitement. |
|
| Trouble concentrating on things such as reading the newspaper or watching television. |
|
| Unable to meet minimum monthly loan or credit card payments. |
|
| Have sold or pawned items to get gambling money. |
|
| Continued gambling despite knowledge of persistent or recurrent physical or psychological problems caused or exacerbated bt gambling. |
|
| Thinking that I would be better off dead or that I want to hurt myself in some way. |
|
| 2. If you checked off any problem on this questionaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? |
|
|
|