Temptation to Drink
Scale Client ID#_________________
Date: ______/______/______
Assessment
Point: _____________
Listed below are a number of situations that lead
some people to Drink Alcohol. We would like to know how tempted you may
be to drink alcohol in each situation.
circle the number that best describes your feelings
of temptation to drink alcohol in each situation during the past week
according to the following scale:
1=Not at all tempted
2=Not very tempted
3=Moderately tempted
4=Very tempted
5=Extremely tempted
|
Situation |
Tempted to
drink alcohol |
||||
|
|
Not
at all |
Not
very |
Moderately |
Very |
Extremely |
|
1) When I am in agony because of
stopping or withdrawing from alcohol use. |
1 |
2 |
3 |
4 |
5 |
|
2) When I have a headache. |
1 |
2 |
3 |
4 |
5 |
|
3) When I am feeling depressed. |
1 |
2 |
3 |
4 |
5 |
|
4) When I am on vacation and want to
relax. |
1 |
2 |
3 |
4 |
5 |
|
5) When I am concerned about someone. |
1 |
2 |
3 |
4 |
5 |
|
6) When I am worried. |
1 |
2 |
3 |
4 |
5 |
|
7) When I have the urge to try just one
drink to see what happens. |
1 |
2 |
3 |
4 |
5 |
|
8) When I am being offered a drink in a
social situation. |
1 |
2 |
3 |
4 |
5 |
|
9) When I dream about taking a drink. |
1 |
2 |
3 |
4 |
5 |
|
10) When I want to test my will power
over drinking. |
1 |
2 |
3 |
4 |
5 |
|
Situation |
Tempted to
drink alcohol |
||||
|
|
Not
at all |
Not
very |
Moderately |
Very |
Extremely |
|
11) When I am feeling a physical need or
craving for alcohol. |
1 |
2 |
3 |
4 |
5 |
|
12) When I am physically tired. |
1 |
2 |
3 |
4 |
5 |
|
13) When I am experiencing some physical
pain or injury. |
1 |
2 |
3 |
4 |
5 |
|
14) When I feel like blowing up because
of frustration. |
1 |
2 |
3 |
4 |
5 |
|
15) When I see others drinking at a bar
or a party. |
1 |
2 |
3 |
4 |
5 |
|
16) When I sense everything is going
wrong for me. |
1 |
2 |
3 |
4 |
5 |
|
17) When people I used to drink with
encourage me to drink. |
1 |
2 |
3 |
4 |
5 |
|
18) When I am feeling angry inside. |
1 |
2 |
3 |
4 |
5 |
|
19) When I experience an urge or impulse
to take a drink that catches me unprepared. |
1 |
2 |
3 |
4 |
5 |
|
20) When I am excited or celebrating with
others. |
1 |
2 |
3 |
4 |
5 |
(12-Item Version)
Temptation to Drink
Scale Client ID#_________________
Date: ______/______/______
Assessment
Point: _____________
Listed below are a number of situations that lead
some people to Drink Alcohol. We would like to know how tempted you may
be to drink alcohol in each situation.
circle the number that best describes your feelings
of temptation to drink alcohol in each situation during the past week
according to the following scale:
1=Not at all tempted
2=Not very tempted
3=Moderately tempted
4=Very tempted
5=Extremely tempted
|
Situation |
Tempted to
drink alcohol |
||||
|
|
Not
at all |
Not
very |
Moderately |
Very |
Extremely |
|
1) When I am feeling depressed. |
1 |
2 |
3 |
4 |
5 |
|
2) When I am concerned about someone. |
1 |
2 |
3 |
4 |
5 |
|
3) When I am worried. |
1 |
2 |
3 |
4 |
5 |
|
4) When I have the urge to try just one
drink to see what happens. |
1 |
2 |
3 |
4 |
5 |
|
5) When I want to test my will power
over drinking. |
1 |
2 |
3 |
4 |
5 |
|
6) When I am feeling a physical need or
craving for alcohol. |
1 |
2 |
3 |
4 |
5 |
|
7) When I am physically tired. |
1 |
2 |
3 |
4 |
5 |
|
8) When I am experiencing some physical
pain or injury. |
1 |
2 |
3 |
4 |
5 |
|
9) When I feel like blowing up because
of frustration. |
1 |
2 |
3 |
4 |
5 |
|
10) When I see others drinking at a bar
or a party. |
1 |
2 |
3 |
4 |
5 |
|
11) When people I used to drink with
encourage me to drink. |
1 |
2 |
3 |
4 |
5 |
|
12) When I am excited or celebrating with
others. |
1 |
2 |
3 |
4 |
5 |