6. There are times when I am very unhappy.

OAI
Instructions
Your records may be reviewed to verify the
information you provide. Do not give false
information.
The statements in this booklet are numbered.
Read each statement carefully and mark your
answer sheet accurately. All statements must
be answered. Do not skip any questions.
Complete the information at the top of your
answer sheet. Do not make any marks on this
booklet.
Drinking refers to beer, wine and other liquor.
Drugs refer to illegal drugs such as marijuana,
cocaine, crack, amphetamines, barbiturates or
heroin.

7. I often drink more or use more drugs than I

intended.
8. I have used drugs (marijuana, crack,
cocaine, amphetamines, barbiturates or
heroin) more than I should.
9. I show my frustrations and anger quickly.
10. When I get angry or upset I yell and throw
or break things.
11. It bothers me when I am overlooked or
ignored by people I know.
12. My drinking is more than just a little or
mild problem.
13. Smoking marijuana helps me settle down,
relax and feel good.
14. There have been times when I have been
jealous or resentful of others.
15. I do not need help with my life or problems.

When you understand these instructions, you

may begin.
Section 1
Answer the following statements True or False.
If a statement is True put an X under T for True.
If a statement is False put an X under F for False
on your answer sheet.

16. There are times I get so angry I cannot

control myself.
17. When I drink my personality changes and I
seem like a different person.
18. There are times when I am really depressed.

1. Sometimes I worry about what other people

think or say about me.

19. I have a lot of anger, resentment and

hostility towards others.

2. I am concerned about my drinking.

20. When offered drugs, I may or may not use

them. It depends on how I feel at the time.

3. I have been told I have a drug problem.

4. I can handle my own problems and do not
want or need help.

21. If someone hurts or insults me, I usually try

to get even.

5. I am a nonviolent person.

22. I was not caught for some of the things I

have done that were wrong.

23. I have been told I have a drinking problem.

24. Two or more of the following apply to me
(answer true or false on your answer sheet):
a. Irritable and uncooperative
b. Disruptive and resentful
c. Confrontive and resistant
d. Touchy and argumentative
e. Sensitive, feelings easily hurt
25. My use of drugs has threatened my
happiness and success in life.
26. Compared to others my age, I am more
destructive or dangerous.
27. There are times when I am concerned that
others may not approve of me.
28. Within the last three years, I have had two
or more blackouts (memory loses) after
drinking.
29. When angry I shout and swear a lot.
30. I have gone to Narcotics Anonymous (NA)
or Cocaine Anonymous (CA) meetings
because of my drug use.
31. I have threatened or physically hurt
someone.
32. I spend a lot of time getting alcohol and/or
drugs, using them or recovering from their
effects.

37. I can be dangerous when frustrated, insulted

or angered.
38. I have been embarrassed or worried about
mistakes I have made.
39. I am outspoken and argumentative.
40. I do not have any problems I want to
discuss with the staff.
41. I lose my temper quickly.
42. I have been in a chemical dependency
treatment program for my drug problem.
43. There are times
discouraged.

when

get

very

44. In the last year, drinking has been a problem

for me.
45. I want help and advice about how to deal
with my problems.
46. I have lied to people about my use of drugs
-- either minimizing how much I use, or
hiding the fact that I use drugs at all.
47. Two or more of the following apply to me
(answer true or false on your answer sheet):
a. Brutal or violent
b. Uncontrollable or cruel
c. Explosive or dangerous
d. Fighting or argumentative

33. There are times when I really worry about

my responsibilities and happiness.
34. I am a recovering alcoholic. I have an
alcohol-related problem, but do not drink
anymore.
35. I want help and assistance from the staff.
36. I have tried to cut down or stop using drugs,
but I still use them.

e. Vengeful or carry a grudge

48. I do not always tell the whole truth when
asked about my finances or personal life.
49. I have a drinking or alcohol-related
problem.
50. I often think about revenge and how I can
get even.

51. I have gone to someone for help about my

drug-related problem.

67. I have said or done things when angry or

mad that I regret.

52. I have many problems and conflicts with

other people.

68. I have continued my alcohol and/or drug use

despite recurrent arguments or fights with
family members about my substance use.

53. Important
social,
occupational
or
recreational activities have been given up or
reduced because of my alcohol and/or drug
use.
54. There are times when I get frustrated and
really angry.
55. My drinking is a serious problem.
56. I have problems I cannot solve alone.

69. There are times when I really worry about

myself and my future.
70. I need help to overcome my drinking
problem.
71. To be honest, I will manipulate and lie to
get my way.
72. In the last year, using drugs has been a
problem for me.

57. I have used drugs like marijuana, crack,

cocaine, amphetamines, barbiturates or
heroin within the last year.

73. I have been arrested for assault or a violent

crime.

58. I have a quick temper and need to learn how

to control it.

74. I have been diagnosed as being alcohol

and/or drug dependent.

59. My alcohol and/or drug use has resulted in

absences from school and/or work, or poor
work performance due to hangovers.

75. There have been times when I have been

concerned about my sex life.

60. There have been times when I have had a

job but did not want to go to work.

76. I have lied to people about my drinking-either minimizing how much I really drink,
or hiding the fact that I drink at all.

61. Within the last year, my family has been

concerned about my drinking.

77. My life is my own business and I wish

others would stop bothering me about it.

62. I have neglected my children, household

duties or responsibilities because of my
alcohol and/or drug use.

78. I have a drug abuse or drug-related problem.

63. Most people irritate or annoy me.

64. There have been times I have felt guilty
about using drugs.
65. I am often angry and resentful towards
others.
66. I have to use more alcohol or drugs to get as
high as I did in the past.

79. There have been times when I have been

physically cruel to someone and
deliberately hurt them.
80. Sometimes I get angry and upset at myself.
81. I have asked for help with my drinking or
alcohol-related problem.
82. There are times when I worry about
probation or even jail or prison.

83. I am in treatment for a drug problem.

84. People tell me I have a quick temper and a
bad attitude.
85. I continue to use drugs despite family
arguments about my drug use.
86. There are times when I am concerned that
others may think badly of me.
87. I have been treated (counseling, outpatient
or inpatient) for a drinking problem.
88. I am a recovering drug abuser. I have not
used drugs for at least a month, but I have a
drug-related problem.
89. There are times when I am really down,
depressed and discouraged.

Section 2
Rate yourself on the next series of statements. Put
an X under the number (1, 2, 3 or 4) that applies to
you now. Use the following rating scale.
1. Rare or Never
2. Sometimes

3. Often
4. Very Often

100. Exercise/Physical Activity

101. Positive Attitude/Outlook
102. Dissatisfied with Life
103. Good Sense of Humor/Laugh
104. Anxious/Worried/Fearful
105. Depressed/Discouraged
106. Insomnia/Trouble Sleeping

90. I have been told I am an alcoholic.

107. Satisfied with Self/Like Self

91. When I get angry I can be dangerous.

108. Financially Stable/Responsible

92. I get upset when others criticize me.

109. Enthusiastic/Involved in Life

93. There are times when I get so angry I

cannot control myself.
94. I have attended Alcoholics Anonymous
(AA) meetings for help with my drinking.
95. I am dependent on drugs and may be
addicted to them.
96. I continue to drink or use drugs even though
I am aware of the harmful effects of
repeated alcohol and/or drug use.
97. I am a violent person.
98. I frequently think about death, dying or
suicide.
99. It has been difficult to answer some of these
questions true or false.

110. Tension/Stress/Nervous
111. Fatigued/Tired/Sluggish
112. Directly Deal with Problems
113. Emotionally Upset/Crying
114. Angry/Hostile with Others
115. Lonely/Unhappy
116. Able to Handle Life's Problems
117. Nervous/Unable to Relax
118. Patient/Tolerant/Understanding
119. Can't Make Decisions/Indecisive
120. Work/Job Satisfaction
121. Admit My Errors/Mistakes

Section 2, continued
122. Bored/Restless/Uninterested
123. Accept Constructive Criticism
124. Trust My Own Judgment
125. Stomach Problems/Acidity
126. Difficulty with Others/Conflict
127. Adaptable/Adjustable
128. Marital/Family Problems
129. Self-Reliant/Independent
130. Agreeable/Cooperative/Reasonable

138. My repeated alcohol and/or drug use has

resulted in:
1. Substance-related legal problems
2. Alcohol and/or drug-related arrests
3. Both 1 and 2
4. None of the above
139. I have continued alcohol and/or drug use
despite persistent or recurrent:
1. Social or interpersonal problems
2. Arguments or fights with family or my
significant other about my substance use
3. Both 1 and 2
4. None of the above

131. Disrespectful/Disagreeable
132. Loss of Control/Explode/Blow-up
133. Uncooperative/Resistant/Defiant
134. Manipulative/Conning/Lying
135. Argumentative/Confrontive/Hostile

Section 3
Select the answer to each of the following
statements that is accurate for you. Put an X
under the number (1, 2, 3 or 4) that applies to you
now.
136. My repeated alcohol and/or drug use has
resulted in:
1. Absences or poor performance at school
or work due to substance use or
recovery from hangovers
2. My neglecting children and/or household
duties and responsibilities
3. Both 1 and 2
4. None of the above
137. I have repeatedly used alcohol and/or
drugs:
1. In physically hazardous or dangerous
situations like swimming, boating or skiing
2. Before driving or operating machinery
3. Both 1 and 2
4. None of the above

140. I have:
1. Had serious physical, social, emotional
or mental problems due to my use of
alcohol and/or drugs
2. Continued to use alcohol and/or drugs
even though I know they cause serious
problems for me
3. Both 1 and 2
4. None of the above
141. I have noticed within the last year:
1. I use a lot more alcohol and/or drugs to
get intoxicated or high
2. I do not get intoxicated or high when
I use the same amount of alcohol or
drugs that I used to use
3. Both 1 and 2
4. None of the above
142. I have had withdrawal symptoms like
trouble sleeping, tremors, sweating,
headaches, nausea or vomiting:
1. After reducing alcohol and/or drug use
2. When I stopped heavy alcohol and/or
drug use
3. Both 1 and 2
4. None of the above

143. With regard to alcohol or drug use, I:

1. Use alcohol or drugs to avoid
withdrawal symptoms
2. Take more alcohol and/or drugs to
relieve or reduce withdrawal symptoms
3. Both 1 and 2
4. None of the above

148. I have:
1. Cut down or stopped doing many of the
things I used to do because of alcohol or
drugs
2. Spent more time using alcohol or drugs
and less time with my family or hobbies
3. Both 1 and 2
4. None of the above

144. When drinking or using drugs I often:

1. Use more (larger amounts) than I intended
2. Use over a longer period than I intended
3. Both 1 and 2
4. None of the above

149. How would you describe your drinking?

1. Serious problem
2. Moderate problem
3. Mild or slight problem
4. No problem

145. I have tried but I cannot:

1. Reduce, cut down or control my use
of alcohol and/or drugs
2. Stop using alcohol and/or drugs
3. Both 1 and 2
4. None of the above

150. How much motivation or desire do you

have for alcohol rehabilitation, treatment or
help?
1. Want help (highly motivated)
2. Undecided (some motivation)
3. Handle it myself (little motivation)
4. No need (not motivated)

146. With regard to alcohol and/or drugs, I:

1. Spend a lot of time obtaining or
getting alcohol or drugs
2. Spend a lot of time taking or recovering
from alcohol or drugs
3. Both 1 and 2
4. None of the above

151. How many different treatment programs

for alcohol problems have you been
enrolled in?
1. One
2. Two or three
3. Four or more
4. None

147. I have been high, drunk or have had

withdrawal symptoms after using alcohol or
drugs:
1. Before or during school, work or
important family functions
2. While driving a vehicle (car, truck or
machinery)
3. Both 1 and 2
4. None of the above

152. Recovering means having an alcohol or

drug problem, but not using or abusing
them anymore. I am a recovering:
1. Alcoholic (beer, wine or liquor)
2. Drug abuser (marijuana, crack, cocaine,
amphetamines, barbiturates or heroin)
3. Both 1 and 2
4. None of the above

153. How would you describe your drug use?

1. Serious problem
2. Moderate problem
3. Mild or slight problem
4. No problem

154. How many different treatment programs

for drug problems have you been enrolled
in?
1. One
2. Two or three
3. Four or more
4. None

155. How much motivation or desire do you

have for drug rehabilitation, treatment or
help?
1. Want help (highly motivated)
2. Undecided (some motivation)
3. Handle it myself (little motivation)
4. No need (not motivated)

156. How would you describe your present

situation? I have serious:
1. Family problems
2. Marital or relationship problems
3. Both 1 and 2 (family and relationship
problems)
4. None of the above
157. I have been arrested for:
1. A violent crime
2. A crime involving force or the threat
of force
3. Both 1 and 2
4. None of the above
158. During the last six months, I have been:
1. Dangerous to myself (suicidal)
2. Dangerous to others (homicidal)
3. Both 1 and 2 (suicidal and homicidal)
4. None of the above

Return this booklet and your answer sheet to the staff.

Thank you for your cooperation.

OAI Copyright 1998. ALL RIGHTS RESERVED

Section 1 Put an X under T for True or put an X

under F for False. Do not skip any items.
T
F
T
F
T
F
1. ___ ___ 34. ___ ___
67. ___ ___

OAI
ANSWER SHEET

2. ___ ___ 35.

___ ___

68.

___ ___

3. ___ ___ 36.

___ ___

69.

___ ___

NAME or ID#: _______________________________

4. ___ ___ 37.

___ ___

70.

___ ___

AGE: ____________ SEX: _____________________

5. ___ ___ 38.

___ ___

71.

___ ___

6. ___ ___ 39.

___ ___

72.

___ ___

7. ___ ___ 40.

___ ___

73.

___ ___

8. ___ ___ 41.

___ ___

74.

___ ___

9. ___ ___ 42.

___ ___

75.

___ ___

10.

___ ___ 43.

___ ___

76.

___ ___

11.

___ ___ 44.

___ ___

77.

___ ___

12.

___ ___ 45.

___ ___

78.

___ ___

13.

___ ___ 46.

___ ___

79.

___ ___

14.

___ ___ 47.

___ ___

80.

___ ___

15.

___ ___ 48.

___ ___

81.

___ ___

16.

___ ___ 49.

___ ___

82.

___ ___

17.

___ ___ 50.

___ ___

83.

___ ___

18.

___ ___ 51.

___ ___

84.

___ ___

19.

___ ___ 52.

___ ___

85. ___ ___

20.

___ ___ 53.

___ ___

86. ___ ___

21.

___ ___ 54.

___ ___

87. ___ ___

22.

___ ___ 55.

___ ___

88. ___ ___

23.

___ ___ 56.

___ ___

89. ___ ___

24.

___ ___ 57.

___ ___

90. ___ ___

ETHNICITY (Race): _________________________

MARITAL STATUS: _________________________
EDUCATION (Highest Grade Completed): ________
DATE OF BIRTH: ________/_______/________
MONTH

DAY

YEAR

TODAYS DATE: ________/_______/________

MONTH

DAY

YEAR

Complete the following information. Number

refers to the total number in your lifetime.
1. Your age at your first arrest:

________

2. Number of felony arrests:

________

3. Number of times on probation:

________

4. Number of probation revocations:

________

5. Number of times on parole:

________

6. Total number of times arrested:

________

25.

___ ___ 58.

___ ___

91. ___ ___

7. Number of times sentenced to jail:

________

26.

___ ___ 59.

___ ___

92. ___ ___

27.

___ ___ 60.

___ ___

93. ___ ___

28.

___ ___ 61.

___ ___

94. ___ ___

29.

___ ___ 62.

___ ___

95. ___ ___

30.

___ ___ 63.

___ ___

96. ___ ___

31.

___ ___ 64.

___ ___

97. ___ ___

32.

___ ___ 65.

___ ___

98. ___ ___

33.

___ ___ 66.

___ ___

99. ___ ___

8. Number of times sentenced to prison:

________

9. Number of alcohol-related arrests:

________

10. Number of drug-related arrests:

________

11. Number of months employed in last 12 months: ___

Section 2

Section 3

Put an X under the number (1, 2, 3, or 4) that describes

you best. Use the following scale to select your answers.

Put an X under the number

(1, 2, 3, or 4) that is most
accurate for you.

1. Rare or Never
2. Sometimes
1

3. Often
4. Very Often
1

1
2
3
4
136. ____ ____ ____ ____
137. ____ ____ ____ ____

100. ____ ____ ____ ____

118. ____ ____ ____ ____

101. ____ ____ ____ ____

119. ____ ____ ____ ____

102. ____ ____ ____ ____

120. ____ ____ ____ ____

140. ____ ____ ____ ____

103. ____ ____ ____ ____

121. ____ ____ ____ ____

141. ____ ____ ____ ____

104. ____ ____ ____ ____

122. ____ ____ ____ ____

138. ____ ____ ____ ____

139. ____ ____ ____ ____

142. ____ ____ ____ ____

143. ____ ____ ____ ____

105. ____ ____ ____ ____

123. ____ ____ ____ ____

106. ____ ____ ____ ____

124. ____ ____ ____ ____

145. ____ ____ ____ ____

107. ____ ____ ____ ____

125. ____ ____ ____ ____

146. ____ ____ ____ ____

108. ____ ____ ____ ____

126. ____ ____ ____ ____

144. ____ ____ ____ ____

147. ____ ____ ____ ____

148. ____ ____ ____ ____

109. ____ ____ ____ ____

127. ____ ____ ____ ____

110. ____ ____ ____ ____

128. ____ ____ ____ ____

150. ____ ____ ____ ____

111. ____ ____ ____ ____

129. ____ ____ ____ ____

151. ____ ____ ____ ____

112. ____ ____ ____ ____

130. ____ ____ ____ ____

149. ____ ____ ____ ____

152. ____ ____ ____ ____

153. ____ ____ ____ ____

113. ____ ____ ____ ____

131. ____ ____ ____ ____

114. ____ ____ ____ ____

132. ____ ____ ____ ____

155. ____ ____ ____ ____

115. ____ ____ ____ ____

133. ____ ____ ____ ____

156. ____ ____ ____ ____

154. ____ ____ ____ ____

157. ____ ____ ____ ____

116. ____ ____ ____ ____

134. ____ ____ ____ ____

117. ____ ____ ____ ____

135. ____ ____ ____ ____

158. ____ ____ ____ ____