Survey

Have you ever sold anything to finance gambling? *

Yes

No

Did you ever gamble longer than you had planned? *

Yes

No

Did you ever lose time from work due to gambling? *

Yes

No

Has gambling ever made your home life unhappy? *

Yes

No

Did gambling affect your reputation? *

Yes

No

Have you ever felt remorse after gambling? *

Yes

No

Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties? *

Yes

No

Did gambling cause a decrease in your ambition or efficiency? *

Yes

No

After losing, did you feel you must return as soon as possible and win back your losses? *

Yes

No

After a win, did you have a strong urge to return and win more? *

Yes

No

Did you often gamble until your last dollar was gone? *

Yes

No

Did you ever borrow to finance your gambling? *

Yes

No

Were you reluctant to use "gambling money" for normal expenditures? *

Yes

No

Did gambling make you careless of the welfare of yourself and your family? *

Yes

No

Did you ever gamble longer than you had planned? *

Yes

No

Have you ever gambled to escape worry or trouble? *

Yes

No

Have you ever committed, or considered committing, an illegal act to finance gambling? *

Yes

No

Did gambling cause difficulty in sleeping? *

Yes

No

Do arguments, disappointments or frustrations create within you an urge to gamble? *

Yes

No

Did you ever have an urge to celebrate any good fortune by a few hours of gambling? *

Yes

No

Have you ever considered self destruction or suicide as a result of your gambling? *

Yes

No

Preferred Type of Gambling: *

Bingo

Cards

Dice

Horses or Dogs

Internet

Lottery

Riverboat/Casino

Slots

Sports Betting

Stock Market

Video Poker

Other

Sex

Male

Female