Questionnaire: Drug Abuse Screening Test (part of Client Intake) NameDate MM slash DD slash YYYY Instructions: Circle the word "Yes" or "No", which honestly describes your position in regard to each of the questions below. The key to answering the questions is honesty.1. Have you used drugs other than those required for medical reasons? Yes No 2. Have you ever 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 (other than those used for medical reasons)? Yes No 5. Are you always able ot stop using drugs when you want to? Yes No 6. Do you abuse drugs on a continuous basis? Yes No 7. Do you try to limit your drug use to certain situations? Yes No 8. Have you had "blackouts" or "flashbacks" as a result of drug use? Yes No 9. Do you ever feel bad about your drug abuse? Yes No 10. Does your spouse (or parents) ever complain about your involvement with drugs? Yes No 11. Do your friends or relatives know or suspect you abuse drugs? Yes No 12. Has drug abuse ever created problems between you and your spouse? Yes No 13. Has any family member ever sought help for problems related to your drug use? Yes No 14. Have you ever lost friends because of your use of drugs? Yes No 15. Have you ever neglected your family or missed work because of your drug use? Yes No 16. Have you ever been in trouble at work because of drug abuse? Yes No 17. Have you ever lost a job because of drug abuse? Yes No 18. Have you gotten into fights when under the influence of drugs? Yes No 19. Have you ever been arrested because of unusual behavior while under the influence of drugs? Yes No 20. Have you ever been arrested for driving while under the influence of drugs? Yes No 21. Have you engaged in illegal activities to obtain drugs? Yes No 22. Have you ever been arrested for possession of illegal drugs? Yes No 23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake? Yes No 24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, or bleeding)? Yes No 25. Have you ever gone to anyone for help for a drug problem? Yes No 26. Have you ever been in the hospital for medical problems related to your drug use? Yes No 27. Have you ever been involved in a treatment program specifically related to drug use? Yes No 28. Have you ever been treated as an outpatient for problems related to drug abuse? Yes No Δ
