MAST screening

MAST screening

Select Yes or No to respond to the following questions. The purpose of this screening test is to enable us to develop a program which will best your needs. Honesty is required in order for this process to meaningful.

Name *
E-mail Address *
Phone Number: *
Do you feel you are a normal drinker? ("normal"= drink as much or less than most people). *	Yes No
Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening? *	Yes No
Does any near relative or close friend ever worry or complain about your drinking? *	Yes No
Can you stop drinking without difficulty after one or two drinks? *	Yes No
Do you ever feel guilty about your drinking? *	Yes No
Have you ever attended a meeting of Alcoholics Anonymous (AA)? *	Yes No
Have you ever gotten into physical fights when drinking? *	Yes No
Has drinking ever created problems between you and a near relative or close friend? *	Yes No
Has any family member or close friend gone to anyone to help about your drinking? *	Yes No
Have you ever lost friends because of your drinking? *	Yes No
Have you ever gotten into trouble at work because of drinking? *	Yes No
Have you ever lost a job because of drinking? *	Yes No
Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking? *	Yes No
Do you drink before noon faily often? *	Yes No
Have you ever been told you have liver trouble such as cirrhosis? *	Yes No
After heavy drinking have you ever had delirium tremens (D.T.'s), severe shaking, visual or auditory (hearing) hallucinations? *	Yes No
Have you ever gone to anyone for help about your drinking? *	Yes No
Have you ever been hospitalized because of your drinking? *	Yes No
Has your drinking ever resulted in your being hospitalized in a psychiatric ward? *	Yes No
Have you ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem? *	Yes No
Have you been arrested more than once for driving under the influence of alcohol? *	Yes No
Have you ever been arrested, even for a few hours because of other behavior while drinking? *	Yes No
If you answered yes to the above question, how many times? *