The following questions
concern your use of any drugs or medication within the
past 12 months. The questions are concerned with your
involvement with drug use only, not alcoholic beverages.
. “Abuse” of drugs
refers to:
1.
The use of prescribed or “ over the
counter drugs” to excess of the directions
2.
any non-medical (illicit) use of drugs
. The questions refer to
the past 12 months.
Instructions:
Carefully read each statement and decide whether your
answer is yes or no.
Have you used drugs other than
those required for medical reasons?
Have you almost abused
prescription drugs?
YesNo
Do you abuse more than one drug at
a time?
YesNo
Can you get through the week
without using drugs (other than required for medical
reasons)?
YesNo
Are you always able to stop using drugs when you want
to?
YesNo
Have you had “blackouts” or “flashbacks” as a result of
drug use?
YesNo
Do you ever feel bad or guilty about your drug abuse?
YesNo
Does your spouse (or parents) ever complain about your
involvement in with drugs?
YesNo
Has drug abuse ever created problems between you and
your spouse or your parents?
YesNo
1.
Have you ever neglected your family because of your use
of drugs?
YesNo
1.
Have you ever lost friends because of your use of drugs?
YesNo
1.
Have you ever been in trouble at work because of drug
abuse?
YesNo
Have you ever lost a job because of drug abuse?
YesNo
Have you gotten into fights when under the influence of
drugs?
YesNo
Have you engaged in illegal activities to obtain drugs?
YesNo
Have you ever been arrested for possession of illegal
drugs?
YesNo
Have you ever experienced withdrawal symptoms when you
stopped taking drugs?
YesNo
Have you had medical problems as a result of your drug
use?
YesNo
Have you ever gone to anyone for help with a drug
problem?
YesNo
Have you been involved in a treatment program
especially related to drug use?
