With you on the road to your recovery.

Drug Questionaire

The following questions concern information about your potential involvement with drugs not including alcoholic beverages during the past 12 months

Have you used drugs other than those required for medical reasons? YES (1) NO (0)
Have you abused prescription drugs? YES (1) NO (0)
Do you abuse more than one drug at a time? YES (1) NO (0)
Can you get through the week without using drugs? YES (0) NO (1)
Are you always able to stop using drugs when you want to? YES (0) NO (1)
Have you had “blackouts” or “flashbacks” as a result of drug use? YES (1) NO (0)
Do you ever feel bad or guilty about your drug use? YES (1) NO (0)
Does you spouse (or parents) ever complain about your involvement with drugs? YES (1) NO (0)
Has drug abuse created problems between you and your spouse or your parents? YES (1) NO (0)
Have you lost friends because of your use of drugs? YES (1) NO (0)
Have you neglected your family because of your use of drugs? YES (1) NO (0)
Have you been in trouble at work because of drug abuse? YES (1) NO (0)
Have you lost a job because of drug use? YES (1) NO (0)
Have you gotten into fights when under the influence of drugs? YES (1) NO (0)
Have you engaged in illegal activities in order to obtain drugs? YES (1) NO (0)
Have you been arrested for possession of illegal drugs? YES (1) NO (0)
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drug YES (1) NO (0)
Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc)? YES (1) NO (0)
Have you gone to anyone for help for drug problem? YES (1) NO (0)
Have you been involved in a treatment program specifically related to drug use? YES (1) NO (0)

Drug Abuse Screening

Test Score Problem Severity
0 No Problem
1-5 Low level of problems related to drug abuse
6-10 Moderate level of problems related to drug abuse
11-15 Substantial level of problems related to drug abuse
16-20 Severe level of problems related to drug abuse