1.		Did you ever lose time from work 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 other-wise 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 and your family?
14.		Did you ever gamble longer than you had planned?
15.		Have you ever gambled to escape worry or trouble?
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 as a result of your gambling?