Drug Addiction Assessment

Using drugs can affect your health, this is also true for some medications you may take. Please help us provide you with he best medical care by answering the questions below.

Methamphetamines(speed, crystal)
Cannabis(marijuana, pot)
Inhalants(paint thinner, aerosol, glue)
Tranqualizers(valium)
Cocaine
Narcotics (heroin, oxycodone, methadone, etc.)
Hallucinogens(LSD, Mushrooms)
Other

How ofthen have you used these drugs?

Monthly or less
Weekly
Daily or almost daily

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

No
Yes

Do you abuse more than one drug at a time?

No
Yes

Are you unable to stop using drugs when you want to?

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

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

No
Yes

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

No
Yes

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

No
Yes

Have you ever injected drugs?

Never
Yes, in the past 90 days
Yes, more than 90 days ago

Have you ever been in treatment for substance abuse?

Never
Currently
In the past