Gambling Addiction Compulsivity Test & Self Assesment

1a. Play Cards for Money
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1b. Bet on Horses, Dogs or other Animals (at OTB, the Track or with a Bookie)
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1c. Bet on sports (parlay cards, with a bookie or at Jai Alai)
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1d. Play dice games (including craps, over and under or other dice games) for money
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1e. Gamble in a casino (legal or otherwise)
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1f. Play the numbers or bet on lotteries
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1g. Play bingo for money
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1h. Play the stock, options and/or commodities market
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1i. Play slot machines, poker machines or other gambling machines
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1j. Bowl, shoot pool, play golf or play any other game of skill for money
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1k. Pull tabs or “paper” games other than lotteries
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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1l. Engage in some form of gambling not listed above (please specify)
Select A ResponseNot At AllLess Than Once A WeekOnce A Week Or More

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2. What is the largest amount of money you have ever gambled with on any one day?
Select A ResponseI've Never Gambled$1 or lessMore than $1 but less than $10More than $10 but less than $100More than $100 but less than $1,000More than $1,000 but less than $10,000More than $10,000

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3. Which of the following people has (or had) a gambling problem?
Select A ResponseFatherMotherBrother or SisterSpouse or PartnerChild or ChildrenGrandparentAnother RelativeNo one in my family has (or had) a gambling problem

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4. When you gamble, how often do you return to win back the money you lost?
Select A ResponseNeverSome of the time (less than half of the times I lost)Most of the times I lostEvery time I lost

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5. Have you ever claimed to be winning money while gambling, even though you were actually losing money?
Select A ResponseNeverYes, less than half of the times I lostYes, most of the time

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6. Do you feel like you have ever had a problem with betting money or gambling?
Select A ResponseNoYes, in the past, but not nowYes

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7. Did you ever gamble more than you intended to?
Select A ResponseYesNo

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8. Have people criticized your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?
Select A ResponseYesNo

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9. Have you ever felt guilty about the way you gamble or what happens when you gamble?
Select A ResponseYesNo

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10. Have you ever felt like you would like to stop betting money or gambling but you didn’t think you could?
Select A ResponseYesNo

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11. Have you ever hidden betting slips, lottery tickets, gambling money, I.O.U.s or other signs of betting or gambling from your spouse, children or other important people in your life?
Select A ResponseYesNo

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12. Have you ever argued with people you live with over how you handle money?
Select A ResponseYesNo

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13. (If you answered yes to question 12) Have money arguments ever centered on your gambling?
Select A ResponseYesNo

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14. Have you ever borrowed from someone and not paid them back as a result of your gambling?
Select A ResponseYesNo

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15. Have you ever lost time from work (or school) due to betting or gambling?
Select A ResponseYesNo

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16. If you borrowed money to gamble or to pay gambling debts, who/where did you borrow from? (answer “yes” or “no” to each question)

From Household Money?
Select A ResponseYesNo

From Your Spouse?
Select A ResponseYesNo

From Other Relatives or In-Laws?
Select A ResponseYesNo

From Banks, Loan Companies or Credit Unions?
Select A ResponseYesNo

From Credit Cards?
Select A ResponseYesNo

From Loan Sharks?
Select A ResponseYesNo

You Cashed in Stocks, Bonds or other Securities?
Select A ResponseYesNo

You Sold Personal or Family Property?
Select A ResponseYesNo

You Borrowed on your Checking Account?
Select A ResponseYesNo

You Have (had) a Credit Line with a Bookie?
Select A ResponseYesNo

You Have (had) a Credit Line with a Casino?
Select A ResponseYesNo

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