| 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 abuse 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 use? |
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 abused 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 abuse? |
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 |