Drug Abuse Screening Tool

Drug Abuse Screening Tool

Select Yes or No to respond to the following questions. The purpose of this screening test is to enable us to develop a program which will best your needs. Honesty is required in order for this process to meaningful.

Name *
E-mail Address *
Phone number *
Have you used drugs other than those required for medical reasons? *	Yes No
Have you abused prescription drugs? *	Yes No
Do you abuse more than one drug at a time? *	Yes No
Can you get through the week without using drugs (other than those required for medical reasons)? *	Yes No
Are you always able to stop using drugs when you want to? *	Yes No
Do you abuse drugs on a continuous basis? *	Yes No
Do you try to limit your drug use to certain situations? *	Yes No
Have you had "blackouts" or "flashbacks" as a result of drug use? *	Yes No
Do you ever feel bad about your drug abuse? *	Yes No
Does your spouse (or parents) ever complain about your involvement with drugs? *	Yes No
Do your friends or relatives know or suspect your abuse drugs? *	Yes No
Has drug abuse ever created problems between you and your spouse? *	Yes No
Has any family member ever sought help for problems realated to your drug use? *	Yes No
Have you ever lost friends because of your use of drugs? *	Yes No
Have you ever neglected your family or missed work because of your use of drugs? *	Yes No
Have you ever been in trouble at work because of drug use? *	Yes No
Have you ever lost a job because of drug abuse? *	Yes No
Have you gotten into fights when under the influence of drugs? *	Yes No
Have you ever been arrested because of unusual behavior while under the influence of drugs? *	Yes No
Have you been treated as an outpatient for problems related to drug abuse? *	Yes No
Have you ever been arrested because of unusual behavior while under the influence of drugs? *	Yes No
Have you ever been arrested for driving while under the influence of drugs? *	Yes No
Have you evern engaged in illegal activities to obtain drugs? *	Yes No
Have you ever been arrested for possession of illegal drugs? *	Yes No
Have you ever experienced withdrawl symptoms as a result of heavy drug intake? *	Yes No
Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions or bleeding?) *	Yes No
Have you ever gone to anyone for help for a drug problem? *	Yes No
Have you ever been in the hospital for medical problems related to your drug use? *	Yes No
Have you ever been involved in a treatment program specifically related to drug use? *	Yes No