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Name_______ |
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Date_______ |
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Score_______ |
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Yes No |
1. |
Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs? |
____ ____ |
2. |
Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? |
____ ____ |
3. |
Do you ever use alcohol or drugs while you are by yourself alone? |
____ ____ |
4. |
Do you ever forget things you did while using alcohol or drugs? |
____ ____ |
5. |
Do your family or friends ever tell you that you should cut down on your drinking or drug use? |
____ ____ |
6. |
Have you ever gotten into trouble while you were using alcohol or drugs? |
____ ____ |
