Check
each characteristic you experience (during the past 12
months)
____
Have you used drugs other than those required for medical purposes?
____ Have you abused prescription drugs?
____ Do you abuse more than one drug at
a time?
____ Can you get through the week without
using drugs?
____ Are you always able to stop using drugs
when you want to?
____ Have you had “blackouts”
or “flashbacks” as a result of drug use?
____ Do you ever feel bad or guilty about
your drug use?
____ Does your spouse (or parents) ever
complain about your involvement with drugs?
____ Has a drug abuse created problems between
you and your spouse or parents?
____ Have you lost friends because of your
drug use?
____ Have you neglected your family because
of your use of drugs?
____ Have you been in trouble at work because
of drug abuse?
____ Have you lost a job because of drug
abuse?
____ Have you gotten into fights when under
the influence of drugs?
____ Have you engaged in illegal activities
in order to obtain drugs?
____ Have you been arrested for possession
of illegal drugs?
____ Have you ever experienced withdrawal
symptoms (felt sick) when you stopped taking drugs?
____ Have you had medical problems as a
result of your drug use? (e.g. memory loss, hepatitis, convulsions,
bleeding, etc.)
____ Have you gone to anyone for help with
a drug problem?
____ Have you been involved in a treatment
program specifically related to drug use?
