Have you used drugs other than those required for medical reasons?
YES
NO

Have you abused prescription drugs?
YES
NO

Do you abuse more than one drug at a time?
YES
NO

Do you use drugs more than once a week?
YES
NO

Have you tried stop using drugs and were not able to do so?
YES
NO

Have you had blackouts or flashbacks as a result of drug use?
YES
NO

Do you ever feel bad or guilty about your drug use?
YES
NO

Does your spouse -or parents - ever complain about your involvement with drugs?
YES
NO

Have you lost friends because of your use of drugs?
YES
NO

Have you neglected your family because of your use of drugs?
YES
NO

Have you been in trouble at work because of your use of drugs?
YES
NO

Have you lost a job because of drug abuse?
YES
NO

Have you gotten into fights when under the influence of drugs?
YES
NO

Have you engaged in illegal activities in order to obtain drugs?
YES
NO

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
YES
NO

Have you had medical problems as a result of your drug use - memory loss, hepatitis, convulsions, bleeding, etc.?
YES
NO

Have you gone to anyone for help for a drug problem?
YES
NO

Have you been involved in a treatment program especially related to drug use?
YES
NO

How to score:
A total score of 4 or more YES is considered clinically significant. We encourage you to call us for a more in-depth consultation, toll free at (800) 527-5344