| 1. | Did you ever lose time from work or school due to gambling? | | |
| 2. | Has gambling ever made your home life unhappy? | | |
| 3. | Did gambling affect your reputation? | | |
| 4. | Have you ever felt remorse after gambling? | | |
| 5. | Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties? | | |
| 6. | Did gambling cause a decrease in your ambition or efficiency? | | |
| 7. | After losing did you feel you must return as soon as possible and win back your losses? | | |
| 8. | After a win did you have a strong urge to return and win more? | | |
| 9. | Did you often gamble until your last dollar was gone? | | |
| 10. | Did you ever borrow to finance your gambling? | | |
| 11. | Have you ever sold anything to finance gambling? | ||
| 12. | Were you reluctant to use "gambling money" for normal expenditures? | | |
| 13. | Did gambling make you careless of the welfare of yourself or your family? | ||
| 14. | Did you ever gamble longer than you had planned? | ||
| 15. | Have you ever gambled to escape worry, trouble, boredom, loneliness, grief or loss? | | |
| 16. | Have you ever committed, or considered committing, an illegal act to finance gambling? | | |
| 17. | Did gambling cause you to have difficulty in sleeping? | | |
| 18. | Do arguments, disappointments or frustrations create within you an urge to gamble? | | |
| 19. | Did you ever have an urge to celebrate any good fortune by a few hours of gambling? | | |
| 20. | Have you ever considered self-destruction or suicide as a result of your gambling? | |
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