MAST Form Date MM slash DD slash YYYY Name First Last Do you feel you are a normal drinker / user? ("normal" - drink as much or less than most other people)(Required) Yes No Have you awakened the morning after some drinking/using the night before and found that you could not remember a part of the evening?(Required) Yes No Does any near relative or close friend ever worry or complain about your drinking/using?(Required) Yes No Can you stop drinking/using without difficulty after one or two drinks?(Required) Yes No Do you ever feel guilty about your drinking/using?(Required) Yes No Have you ever attended a meeting of Alcoholics Anonymous (AA)?(Required) Yes No Have you ever gotten into physical fights when drinking/using?(Required) Yes No Has your drinking/using ever created problems between you and a near relative or close friend?(Required) Yes No Has any family member or close friend gone to anyone for help about your drinking/using?(Required) Yes No Have you ever lost friends because of your drinking/using?(Required) Yes No Have you ever gotten into trouble at work because of drinking/using?(Required) Yes No Have you ever lost a job because of drinking/using?(Required) 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/using?(Required) Yes No Do you drink/use before noon fairly often?(Required) Yes No Have you ever been told you have liver trouble such as cirrhosis?(Required) Yes No After heavy drinking/using have you ever had delirium tremens (D.T.'s), severe shaking, visual or auditory (hearing) hallucinations?(Required) Yes No Have you ever gone to anyone for help about your drinking/using?(Required) Yes No Have you ever been hospitalized because of drinking/using?(Required) Yes No Has your drinking/using ever resulted in your being hospitalized in a psychiatric ward?(Required) 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/using was part of the problem?(Required) Yes No Have you been arrested more than once for driving under the influence of alcohol/drugs?(Required) Yes No Have you ever been arrested, even for a few hours, because of other behavior while drinking/using?(Required) Yes No How many times?(Required)
