(DAST-10)

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

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* 1. Client Information

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

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

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

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

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

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

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

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

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

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

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

0 of 13 answered
 

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