yes no

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

yes no

2. Have you abused prescription drugs?

yes no

3. Do you abuse more than one drug at a time?

yes no

4. Can you get through the week without using drugs?

yes no

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

yes no

6. Have you had "blackouts" or "flashbacks" as a result of drug use?

yes no

7. Has drug abuse created problems between you and your spouse/partner or your parents?

yes no

8. Have you lost friends because of your use of drugs?

yes no

9. Do you ever feel guilty or bad about your drug use?

yes no

10. Does your spouse/partner (or parents) ever complain about your involvement with drugs?

yes no

11. Have you neglected your family because of your use of drugs?

yes no

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

yes no

13. Have you lost a job because of drug abuse?

yes no

14. Have you gotten in fights when under the influence of drugs?

yes no

15. Have you ever engaged in illegal activities in order to obtain drugs?

yes no

16. Have you ever been arrested for possession of illegal drugs?

yes no

17. Have you ever experienced withdrawl symptoms (e.g. felt sick) when you stopped taking drugs?

yes no

18. Have you had medical problems as a result of your drug use?

yes no

19. Have you gone to anyone for help for a drug problem.

yes no

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