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Date:
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During the PAST 12 MONTHS, on how many days did you
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1. Drink more than a few sips of beer, wine, or any drink containing alcohol? Put "0" if none
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2. Use any marijuana (pot, weed, hash, or in foods) or "synthetic marijuana" (like "K2" or "Spice")? Put "0" if none
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3. Use anything else to get high (like other illegal drugs prescription or over-the-counter medications, and things that you sni
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4. How many days in 12 months have use used nicotine?
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Continue to next section if any answer from questions 1- 4 are 1 or more.
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5. Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?
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6. Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in?
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7. Do you ever use alcohol or drugs while you are by yourself, or ALONE?
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8. Do you ever FORGET things you did while using alcohol or drugs?
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9. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
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10. Have you ever gotten into TROUBLE while you were using alcohol or drugs?
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Interpreting the CRAFFT 2.1+N* Any “Yes” responses for questions 5-10 are given one point.
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NOTICE TO CLINIC STAFF AND MEDICAL RECORDS:
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