1. Did you ever lose time from work or school 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. Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?
   Yes No
   
   
6. Did gambling cause a decrease in your ambition or efficiency?
   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. Did you often gamble until your last dollar was gone?
   Yes No
   
   
10. Did you ever borrow to finance your gambling?
    Yes No
    
    
11. Have you ever sold anything to finance gambling?
    Yes No
    
    
12. Were you reluctant to use "gambling money" for normal expenditures?
    Yes No
    
    
13. Did gambling make you careless of the welfare of yourself or your family?
    Yes No
    
    
14. Did you ever gamble longer than you had planned?
    Yes No
    
    
15. Have you ever gambled to escape worry, trouble, boredom or loneliness?
    Yes No
    
    
16. Have you ever committed, or considered committing, an illegal act to finance gambling?
    Yes No
    
    
17. Did gambling cause you to have difficulty in sleeping?
    Yes No
    
    
18. Do arguments, disappointments or frustrations create within you an urge to gamble?
    Yes No
    
    
19. Did you ever have an urge to celebrate any good fortune by a few hours of gambling?
    Yes No
    
    
20. Have you ever considered self destruction or suicide as a result of your gambling?
    Yes No

All finished? Great! Now, go ahead and print this page or write down your answers.

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Prepared by Gamblers Anonymous