Drug Abuse Screening Test

Name *
Name
Date *
Date
A. Have you used drugs other than those required for medical reasons? *
B. Have you abused prescription drugs? *
C. Do you abuse more than one drug at a time? *
**D. Can you get through the week without using drugs? *
Drugs do not include those required for medical reasons.
**E. Are you always able to stop using drugs when you want to? *
F. Do you abuse drugs on a continuous basis? *
**G. Do you try to limit your drug use to certain situations? *
H. Have you had "blackouts" or "flashbacks" as a result of drug use? *
I. Do you ever feel bad about your drug use? *
J. Does your spouse (or parents) ever complain about your involvement with drugs? *
K. Do your friends or relatives know or suspect you abuse drugs? *
L. Has drug abuse ever created problems between you and your spouse? *
M. Has any family member ever sought help for problems related to your drug use? *
N. Have you ever lost friends because of your use of drugs? *
O. Have you ever neglected your family or missed work because of your use of drugs? *
P. Have you ever been in trouble at work because of drug abuse? *
Q. Have you ever lost a job because of drug abuse? *
R. Have you gotten into fights when under the influence of drugs? *
S. Have you ever been arrested because of unusual behavior while under the influence of drugs? *
T. Have you ever been arrested for driving while under the influence of drugs? *
U. Have you engaged in illegal activities in order to obtain drugs? *
V. Have you ever gone to anyone for help with a drug problem? *
W. Have you ever been arrested for possession of illegal drugs? *
X. Have you ever experienced withdrawal symptoms as a result of heavy drug intake? *
Y. Have you had medical problems as a result of your drug use? *
Examples: memory loss, hepatitis, convulsions, & bleeding.
Z. Have you ever been in the hospital for medical problems related to your drug use? *
AA. Have you ever been involved in a treatment program specifically related to drug use? *
BB. Have you ever been treated as an outpatient for problems related to drug abuse? *
Each positive response yields a point of one, except for those questions denoted with a double asterisk- items D, E, and G are scored point of one for "no" response. A score of greater than 5 requires further evaluation for substance abuse.