Dr. Gerald B Harris, II

Last Name *

First Name *

Date *

1. Have you used drugs other than those required for medical reasons? *

Yes

3. Do you misuse more than one drug at a time? *

Yes

Are you always able to stop using drugs when you want to? (if never use drugs, answer "YES") *

Have you had "blackouts or "flashbacks" as a result of drug use?

Do you ever feel bad or guilty about about your drug use? If you never use drugs, choose " NO". *

Does your spouse (or parents) ever complain about your involvement with drugs? *

Have you neglected your family because of your use of drugs? *

Have you engaged in Illegal activities in order to obtain drugs? *

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? *

Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.) *

* Required field