Drug Abuse Screening Test

For each question in test, please choose the option which best describes how often you felt or behaved this way during the past several days.

Name

Phone

City

Has drug abuse ever created problems between you and your spouse?

Yes

Good part of the time

Most of the time

Have you been treated as an outpatient for problems related to drug abuse?

Yes

Have you ever gone to anyone for help for a drug problem?

Yes

Can you get through the week without using drugs
(other than those required for medical reasons)?

Yes

Have you ever been in trouble at work because of drug abuse?

Yes

Do you abuse more than one drug at a time?

Yes

Do you try to limit your drug use to certain situations?

Yes

Have you ever lost a job because of drug abuse?

Yes

Have you ever been arrested for driving while under the influence of drugs?

Yes

Have you ever been arrested for possession of illegal drugs?

Yes

Have you ever been involved in a treatment program specifically related to drug use?

Yes

Have you ever experienced withdrawal symptoms as a result of heavy
drug intake?

Yes

Have you ever been arrested because of unusual behavior while under the influence of drugs?

Yes

Have you engaged in illegal activities in order to obtain drug?

Yes

Have you used drugs other than those required for medical reasons?

Yes

Have you had “blackouts” or “flashbacks” as a result of drug use?

Yes

Have you ever lost friends because of your use of drugs?

Yes

Has any family member ever sought help for problems related to your drug use?

Yes

Does your spouse (or parents) ever complain about your involvement with drugs?

Yes

Do you ever feel bad about your drug abuse?

Yes

Have you abused prescription drugs?

Yes

Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Yes

Have you gotten into fights when under the influence of drugs?

Yes

Are you always able to stop using drugs when you want to?

Yes

Have you ever been in a hospital for medical problems related to your drug use?

Yes

Do your friends or relatives know or suspect you abuse drugs?

Yes

Have you ever neglected your family or missed work because of your use of drugs?

Yes

Do you abuse drugs on a continuous basis?

Yes

29 out of 28