Drug Abuse Screening Test

DAST-10

Using drugs can affect your health and may interact with the medications you take. Please help us provide you with the best medical care by answering the questions below.

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* 1. Information

Name

Date of Birth

Location

State/Province

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* 2. Date of Completion

Date

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* 3. What recreational drugs have you used in the past year?

Methamphetamines (speed, crystal)

Cannabis (marijuana, pot)

Inhalants (paint thinner, aerosol, glue)

Tranquilizers (valium)

Cocaine

Narcotics (heroin, oxycodone, methadone)

Hallucinogens (LSD, mushrooms)

None of the above

Other (please specify)

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* 4. Have you used drugs other than those required for medical reasons?

Yes

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* 5. Do you abuse more than one drug at a time?

Yes

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* 6. Are you able to stop using drugs when you want to?

Yes

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* 7. Have you ever had blackouts or flashbacks as a result of drug use?

Yes

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* 8. Do you ever feel bad or guilty about your drug use?

Yes

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* 9. Does your spouse (or parents) ever complain about involvement with drugs?

Yes

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* 10. Have you neglected your family because of your use of drugs?

Yes

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* 11. Have you engaged in illegal activities in order to obtain drugs?

Yes

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* 12. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

Yes

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

Yes