Never	One to Two Times	Three to Five Times	Six to Ten Times	More Than Ten Times
1. Not able to do your homework or study for a test?	1	2	3	4	5
2. Got into fights, acted badly, or did mean things?	1	2	3	4	5
3. Missed out on other things because you spent too much money on gambling?	1	2	3	4	5
4. Caused shame or embarrassment to someone?	1	2	3	4	5
5. Neglected your responsibilities?	1	2	3	4	5
6. A relative avoided you?	1	2	3	4	5
7. Felt that you needed to gamble more frequently or place higher wagers than you used to use in order to get the same effect?	1	2	3	4	5
8. Tried to control your gambling by trying to gamble only at certain times of the day or in certain places?	1	2	3	4	5
9. Had withdrawal symptoms, that is, felt sick or irritable because you stopped or cut down on gambling?	1	2	3	4	5
10. Noticed a change in your personality?	1	2	3	4	5
11. Felt that you had a problem with gambling?	1	2	3	4	5
12. Missed a day (or part of a day) of school or work?	1	2	3	4	5
13. Tried to cut down or quit gambling?	1	2	3	4	5
14. Had a fight, argument, or bad feelings with a friend?	1	2	3	4	5
15. Had a fight, argument, or bad feelings with a family member?	1	2	3	4	5
16. Kept gambling when you promised yourself not to?	1	2	3	4	5
17. Felt you were going crazy?	1	2	3	4	5
18. Had a bad time?	1	2	3	4	5
19. Felt physically or psychologically dependent?	1	2	3	4	5
20. Was told by a friend or neighbor to stop or cut down gambling?	1	2	3	4	5