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fields (labelled below in red) have been filled in
Please note that all fields followed by an asterisk must be filled in. First Name*
My use has caused me to miss out on activities I enjoy.
I have been secretive about my use.
My use has resulted in behavior that embarrasses me.
My use has resulted in behavior that embarrasses my spouse.
I have tried to manage or control my use but been unable to.
I find it hard to stop using once I begin.
I have needed to spend time recovering from the effects of my use in the past year.
I use more then I intend to.
I have had strong cravings for using.
My use has resulted in unmet obligations to others.
My use has resulted in unmet obligations to myself.
I have experienced physical withdrawal symptoms when not using.
My use has put me in physically dangerous situations.
My use has resulted in criminal charges.
I use in the morning before my day begins.
My tolerance for using has increased.
I have had times when I didn't feel like using but did anyway.
I continue to use despite evidence that my health and general well-being are being negatively impacted.
Filling out this form made me think about my using.
I am in charge of my thoughts, feelings and behaviors
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