1. When you gamble, how often do you go back another day to win back money you lost?
     Some of the time (less than half the time) I lost
     Most of the time I lost
     Every time I lost

2. Have you ever claimed to be winning money gambling but weren’t really? In fact, you lost?
     Never
     Yes, less than half the time I lost
     Yes, most of the time

3. Do you feel you have ever had a problem with gambling?
     No
     Yes, in the past, but not now
     Yes

4. Did you ever gamble more than you intended to?
     Yes
     No

5. Have people criticized your gambling?
     Yes
     No

6. Have you ever felt guilty about the way you gamble or what happens when you gamble?
     Yes
     No

7. Have you ever felt like you would like to stop gambling but didn’t think you could?
     Yes
     No

8. Have you ever hidden betting slips, lottery tickets, gambling money, or other signs of gambling from your spouse, children, or other important people in your life?
     Yes
     No

9. Have you ever argued with people you live with over how you handle money?
     Yes
     No

10. (If you answered yes to question 9): Have money arguments ever centered on your gambling?
     Yes
     No

11. Have you ever borrowed from someone and not paid them back as a result of your gambling?
     Yes
     No

12. Have you ever lost time from work (or school) due to gambling?
     Yes
     No

13. If you borrowed money to gamble or to pay gambling debts who or where did you borrow from? (check “yes” or “no” for each)

  a. From household money 
     Yes
     No
  b. From your spouse 
     Yes
     No
  c. From other relatives or in-laws 
     Yes
     No
  d. From banks, loan companies, or credit unions 
     Yes
     No
  e. From credit cards
     Yes
     No
  f. From loan sharks 
     Yes
     No
  g. You cashed in stocks, bonds, or other securities
     Yes
     No
  h. You sold personal or family property 
     Yes
     No
  i. You borrowed on your checking account 
     Yes
     No