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Name:

__________________________

Date:

1. Please indicate which of the following types of gambling you have done.

For each type, mark one answer which describes the last time you performed each listed behavior and how often you did the behavior. If you check “Not at all” simply go on to the next item as you will not need to report “how often”.

(When you did the behavior)

(How often?)

did any kind of gambling

played cards for money (such as Texas Hold'em, poker, or other card games) bet on horses, dogs, or other animals (at OTB, the track or with a bookie) for money bet on sports for money (including basketball, football, parlay

cards, Jai Alai, or other sports) with friends, a bookie, at work, etc. played dice games (including craps, over and under, or other dice games) for money gambled in a casino or on a casino boat (legal or otherwise) for money played the numbers or bet on lotteries, Kino, or Quick Draw played bingo for money played the stock, options, and /or commodities market played slot machines, poker machines, or other

gambling machines bowled, shot pool, played golf or darts, or some other game of

skill for money pull tabs or "paper" games other than lotteries (such as Lucky 7's) some form of gambling not listed above

(please specify)_____________________________ gambled and used alcohol or drugs at the same time

2. How troubled or bothered have you been, due to your gambling, in the past six months? (Circle one)

Not at all

Slightly

Moderately

Considerably

Extremely

3. Have you ever quit gambling for a period or time? I have never gambled No, I have never quit Yes, more than one year ago to today

Yes, more than six months but less than one year ago to today

Yes, in the past six months to today Yes, in the past month to today Yes, in the past week to today

© 2006. The Long Island Home. All Rights Reserved.

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