ADDICTION SELF-ASSESSMENT

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.

Question Title

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

Yes

Question Title

* 2. Have you used prescription drugs not as prescribed?

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

* 16. Have you been arrested for possession of substances?

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes