Using drugs can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.
Which of the following drugs have you used in the PAST YEAR?
How often have you used these drugs?
1. Have you used drugs other than those required for medical reasons?
2. Do you abuse more than one drug at a time?
3. Are you unable to stop using drugs when you want to?
4. Have you ever had blackouts or flashbacks as a result of drug use?
5. Do you ever feel bad or guilty about your drug use?
6. Does your spouse (or parents) ever complain about your involvement with drugs?
7. Have you neglected your family because of your use of drugs?
8. Have you engaged in illegal activities in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?
Have you ever injected drugs?
Have you ever been in treatment for substance abuse?
(0 = 1)) (1-2 = 2) (3-5 = 3) (6+ = 4)
