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BURNSVILLE FIRE DEPARTMENT

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1. Do you feel you are a normal drinker? ("normal" - drink as much or less than most other people)?
	No
	Yes

2. Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?
	No
	Yes

3. Does any near relative or close friend ever worry or complain about your drinking?
	No
	Yes

4. Can you stop drinking without difficulty after one or two drinks?
	No
	Yes

5. Do you ever feel guilty about your drinking?
	No
	Yes

6. Have you ever attended a meeting of Alcoholics Anonymous (AA)?
	No
	Yes

7. Have you ever gotten into physical fights when drinking?
	No
	Yes

8. Has drinking ever created problems between you and a near relative or close friend?
	No
	Yes

9. Has any family member or close friend gone to anyone for help about your drinking?
	No
	Yes

10. Have you ever lost friends because of your drinking?
	No
	Yes

11. Have you ever gotten into trouble at work because of drinking?
	No
	Yes

12. Have you ever lost a job because of drinking?
	No
	Yes

13. Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?
	No
	Yes

14. Do you drink before noon fairly often?
	No
	Yes

15. Have you ever been told you have liver trouble such as cirrhosis?
	No
	Yes

16. After heavy drinking have you ever had delirium tremens (D.T.?s), severe shaking, visual or auditory (hearing) hallucinations?
	No
	Yes

17. Have you ever gone to anyone for help about your drinking?
	No
	Yes

18. Have you ever been hospitalized because of drinking?
	No
	Yes

19. Has your drinking ever resulted in your being hospitalized in a psychiatric ward?
	No
	Yes

20. Have you ever gone to any doctor, social worker, clergyman or mental health clinic for help with any emotional problem in which drinking was part of the problem?
	No
	Yes

21. Have you been arrested more than once for driving under the influence of alcohol?
	No
	Yes

22. Have you ever been arrested, even for a few hours, because of other behavior while drinking?
	No
	Yes

1. Have you ever felt you should cut down on your drinking?
	No
	Yes

2. Have people annoyed you by criticizing your drinking?
	No
	Yes

3. Have you ever felt bad or guilty about your drinking?
	No
	Yes

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
	No
	Yes

1. In the past 4 weeks, about how often did you feel tired out for no good reason?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

2. In the past 4 weeks, about how often did you feel nervous?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

3. In the past 4 weeks, about how often did you feel so nervous that nothing could calm you down?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

4. In the past 4 weeks, about how often did you feel hopeless?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

5. In the past 4 weeks, about how often did you feel restless or fidgety?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

6. In the past 4 weeks, about how often did you feel so restless you could not sit still?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

7. In the past 4 weeks, about how often did you feel depressed?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

8. In the past 4 weeks, about how often did you feel that everything was an effort?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

9. In the past 4 weeks, about how often did you feel so sad that nothing could cheer you up?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

10. In the past 4 weeks, about how often did you feel worthless?
	None of the time
	A little of the time
	Some of the time
	Most of the time
	All of the time

1. I was bothered by things that don't usually bother me.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

2. I did not feel like eating; my appetite was poor.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

3. I felt that I could not shake off the blues even with the help of my family or friends.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

4. I felt that I was just as good as other people.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

5. I had trouble keeping my mind on what I was doing.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

6. I felt depressed.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

7. I felt everything I did was an effort.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

8. I felt hopeful about the future.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

9. I thought my life had been a failure.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

10. I felt fearful.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

11. My sleep was restless.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

12. I was happy.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

13. I talked less than usual.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

14. I felt lonely.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

15. People were unfriendly.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

16. I enjoyed life.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

17. I had crying spells.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

18. I felt sad.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

19. I felt that people disliked me.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

20. I could not get going.
	Rarely or none of the time (<1 day)
	Some or a little of the time (1-2 days)
	Occasionally or a moderate amount of the time (3-4 days)
	Most or all of the time (5-7 days)

1. Have you used drugs other than those required for medical reasons?
	No
	Yes

2. Have you abused prescription drugs?
	No
	Yes

3. Do you abuse more than one drug at a time?
	No
	Yes

4. Can you get through the week without using drugs?
	No
	Yes

5. Are you always able to stop using drugs when you want to?
	No
	Yes

6. Have you had "blackouts" or "flashbacks" as a result of drug use?
	No
	Yes

7. Do you ever feel bad or guilty about your drug use?
	No
	Yes

8. Does your spouse (or parents) ever complain about your involvement with drugs?
	No
	Yes

9. Has drug abuse created problems between you and your spouse or your parents?
	No
	Yes

10. Have you lost friends because of your use of drugs?
	No
	Yes

11. Have you neglected your family because of your use of drugs?
	No
	Yes

12. Have you been in trouble at work because of your use of drugs?
	No
	Yes

13. Have you lost a job because of drug abuse?
	No
	Yes

14. Have you gotten into fights when under the influence of drugs?
	No
	Yes

15. Have you engaged in illegal activities in order to obtain drugs?
	No
	Yes

16. Have you been arrested for possession of illegal drugs?
	No
	Yes

17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
	No
	Yes

18. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?
	No
	Yes

19. Have you gone to anyone for help for a drug problem?
	No
	Yes

20. Have you been involved in a treatment program especially related to drug use?
	No
	Yes

1. Are you recalling traumatic emergency events that occurred years ago, now on a weekly or daily basis?
	No
	Yes

2. Do you recall traumatic events when you see someone in the general public that looked like a past victim?
	No
	Yes

3. Are you starting to become frustrated or angry when being dispatched for emergency calls?
	No
	Yes

4. Do you find yourself trying to avoid, go out of your way or think about certain situations that remind you of previous calls?
	No
	Yes

5. Do you find yourself feeling guilty or grieving about a patient(s) that died within the last 3 months?
	No
	Yes

6. Have you or someone close to you notice that your sleeping patterns have changed?
	No
	Yes

7. Are you experiencing dreams or nightmares about a past event(s)?
	No
	Yes

8. Have you been told that you have changed? by Friends, Family, or Fellow firefighters?
	No
	Yes

BURNSVILLE FIRE DEPARTMENT

Alcohol Assessment

Alcohol Dependence Assessment

Anxiety & Distress Assessment

Depression Assessment

Drug Abuse Assessment

PTSD Assessment