The following questions refer to the past 12 months and refer to substances not including alcohol.

Substances include, but are not limited to, cannabis, cocaine, methamphetamine, prescription stimulants (adderall, vyvanse), prescription benzodiazepines (xanax, valium), heroin, prescription opioids (oxycodone, fentanyl), kratom, mushrooms, LSD, ketamine, MDMA, molly, and inhalants.

If you have difficulty with a statement, choose the one that is mostly right.

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1. Have you used substances other than those required for medical reasons?

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2. Have you used prescription drugs not as prescribed?

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3. Do you use more than one substance at a time?

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4. Can you get through the week without using substances?

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5. Are you always able to stop using substances when you want to?

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6. Have you had “blackouts” or “flashbacks” as a result of substance use?

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7. Do you ever feel bad or guilty about your substance use?

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8. Does your partner (or parents) ever complain about your involvement with substances?

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9. Has substance use created problems between you and your partner or your parents?

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10. Have you lost friends because of your use of substances?

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11. Have you neglected your family because of your use of substances?

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12. Have you been in trouble at work (or school) because of substance use?

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13. Have you lost your job because of substance use?

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14. Have you gotten into fights when under the influence of substances?

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15. Have you engaged in illegal activities in order to obtain substances?

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16. Have you been arrested for possession of substances?

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17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped using substances?

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

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19. Have you gone to anyone for help for a substance use problem?

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20. Have you been involved in a treatment program specifically related to substance use?

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