South Oaks Gambling Screen for Self


1. Please indicate which of the following types of gambling you have done in your lifetime. For each type, mark one answer: "not at all", "less than once a week", or "once a week or more"

Not at all Less than once a week Once a week or more  
a. play cards for money

b. bet on horses, dogs or other animals (at OTB, the track, or with a bookie)
c. bet on sports (parlay cards, with bookies, or at Jai Alai court)

d. played dice games (including craps, over & under, or other dice games) for money or drinks, etc.
e. gambled in a casino (legal or otherwise)

f. played the numbers or bet the lotteries

g. played bingo for money

h. played the stock, options and or commodities markets

i. played slot machines, poker machines or other game of skill for money
j. pull tabs or "paper" games other than lotteries

k. some other form of gambling not listed above


2. What is the largest amount of money you have ever gambled with on any one-day?
Never have gambled
$1 or less
more then $1 up to $10
more than $10 up to $100
more than $100 up to $1000
more than $10,000
more than $1000 up to $10,000
3. Check which of the following people in your life has (or bad) a gambling problem.
Father
Mother
A brother-in-law
A grandparent
My spouse or partner
My Child (ren)
Another relative
A friend or someone else important in my life
4. When you gamble, how often do you go back another day to win back the money you lost?
Never
Some of the time (less than half of the time I lost
Everytime I lost
Most of the time I lost
5. Have you ever claimed to be winning money gambling but were not really? In fact, you lost?
Never
Yes, most of the time
Yes, less then half the time I lost
6. Do you feel you have ever had a problem with betting money or gambling?
No
Yes
Yes, in the past but not now
7. Did you you ever gamble more than you intended to?
No
Yes
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?
No
Yes
9. Have you ever felt guilty about the way you gamble or what happens when you gamble?
No
Yes
10. Have you ever felt like you would like to stop betting money or gambling but didn't think you could?
No
Yes
11. Have you ever hidden betting slips, lottery tickets, gambling money, IOUs or other signs of betting or gambling from your spouse, children, or other important people in your life?
No
Yes
12. Have you ever argued with people you live with over how you handle money?
No
Yes
13. (If you answered yes to question 12): Have money arguments ever centered around your gambling?
No
Yes
14. Have you ever borrowed from someone and not paid them back as a result of your gambling?
No
Yes
15. Have you ever lost time from work (or school) due to gambling?
No
Yes
16. If you borrowed money to gamble or to pay gambling debts, who or where did you borrow from?
No - Yes
a. from household money
No - Yes
b. from your spouse
No - Yes
c. from other relatives or in-laws
No - Yes
d. from banks, loan companies or credit unions
No - Yes
e. from credit cards
No - Yes
f. from loan sharks
No - Yes
g. you cashed in stocks, bonds, life insurance or other securities
No - Yes
h. you sold personal or family property
No - Yes
i. you borrowed on your checking account (passed bad checks)
No - Yes
j. you have (had) a credit line with a bookie
No - Yes
k.you have (had) a credit line with a casino