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4. What is the largest amount of money you have ever gambled on any one day?

Never have gambled

$1 or less More than $1 up to $10

More than $100 up to $1,000 More than $1,000 up to $10,000 More than $10,000

More than $10 up to $100

5a. Check which of the following people in your life has (or had) a gambling problem.

Father

Mother

A brother or sister

My spouse or partner

My child (ren)

A grandparent Another relative

A friend or someone else important in my life

5b. Have your family members ever been criticized about their gambling? (Check one)

Yes

6. When you gamble, how often do you go back another day to win back money you lost? I do not or have not ever gambled Never Some of the time (less than half the time I lost) Most of the time I lost Every time I lost

7. Do you feel you have had a problem with betting money or gambling? No Yes, in the past but not now Yes

7a. If you answered yes to item seven, how long ago did you have a problem betting? More than one year ago Less than one year ago In the past six months In the past month In the past week

8. Have you ever claimed to be winning money gambling but weren't really? In fact, you lost? I have never gambled Never

Yes, less than half the time I lost Yes, most of the time

Please circle “yes” or “no” for each of the following statements as they describe you.

  • 9.

    Yes

  • 10.

    Yes

  • 11.

    Yes

  • 12.

    Yes

  • 13.

    Yes

  • 14.

    Yes

  • 15.

    Yes

  • 16.

    Yes

  • 17.

    Yes

No No

No No No

No No No No

Did you ever gamble more than you intended to? Have people criticized your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?

Have you ever felt guilty about the way you gamble or what happens when you gamble? Have you ever felt like you would like to stop betting money or gambling but didn’t think you could? Have you ever hidden betting slips, lottery tickets, gambling money, I.O.U.’s or other signs of betting or gambling from your spouse, parents, children, or other important people in your life? Have you ever argued with people you live with over how you handle money? (If you answered yes to question 14): Have money arguments ever centered on your gambling? Have you ever lost time from work or school due to betting money or gambling?

Have you ever borrowed from someone and not paid them back as a result of your gambling?

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

No

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