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Date:
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In the past 12 months ...
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1. Have you used drugs other than those required for medical reasons?
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2. Do you abuse more than one drug at a time?
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3. Are you unable to stop abusing drugs when you want to?
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4. Have you ever had blackouts or flashbacks as a result of drug use?
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5. Do you ever feel bad or guilty about your drug use?
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6. Does your spouse (or parents) ever complain about your involvement with drugs?
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7. Have you neglected your family because of your use of drugs?
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8. Have you engaged in illegal activities in order to obtain drugs?
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9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
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10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?
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Score (Scoring: Score 1 point for each question answered "Yes," except for question 3 for which a "No" receives 1 point)
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