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
|
