1.     Have you used drugs other than those required for medical reasons? |
Yes |
No |
|
2.     Have you abused prescription drugs? |
Yes |
No |
|
3.     Do you abuse more than one drug at a time? |
Yes |
No |
|
4.     Can you get through the week without using drugs (other than those required for medical reasons)? |
Yes |
No |
|
5.     Are you always able to stop using drugs when you want to? |
Yes |
No |
|
6.     Do you abuse drugs on a continuous basis? |
Yes |
No |
|
7.     Do you try to limit your drug use to certain situations? |
Yes |
No |
|
8.     Have you had "blackouts" or "flashbacks" as a result of drug use? |
Yes |
No |
|
9.     Do you ever feel bad about your drug abuse? |
Yes |
No |
|
10.   Does your spouse (or parents) ever complain about your involvement with drugs? |
Yes |
No |
|
11.   Do your friends or relatives know or suspect you abuse drugs? |
Yes |
No |
|
12.   Has drug abuse ever created problems between you and your spouse? |
Yes |
No |
|
13.   Has any family member ever sought help for problems related to your drug use? |
Yes |
No |
|
14.   Have you ever lost friends because of your use of drugs? |
Yes |
No |
|
15.   Have you ever neglected your family or missed work because of your use of drugs? |
Yes |
No |
|
16.   Have you ever been in trouble at work because of drug abuse? |
Yes |
No |
|
17.   Have you ever lost a job because of drug abuse? |
Yes |
No |
|
18.   Have you gotten into fights when under the influence of drugs? |
Yes |
No |
|
19.   Have you ever been arrested because of unusual behavior while under the influence of drugs? |
Yes |
No |
|
20.   Have you ever been arrested for driving while under the influence of drugs? |
Yes |
No |
|
21.   Have you engaged in illegal activities to obtain drugs? |
Yes |
No |
|
22.   Have you ever been arrested for possession of illegal drugs? |
Yes |
No |
|
23.   Have you ever experienced withdrawal symptoms as a result of heavy drug intake? |
Yes |
No |
|
24.   Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, or bleeding)? |
Yes |
No |
|
25.   Have you ever gone to anyone for help for a drug problem? |
Yes |
No |
|
26.   Have you ever been in hospital for medical problems related to your drug use? |
Yes |
No |
|
27.   Have you ever been involved in a treatment program specifically related to drug use? |
Yes |
No |
|
28.   Have you been treated as an outpatient for problems related to drug abuse? |
Yes |
No |
|