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Is my use problematic?
1.
This survey is completely confidential, and your answers in no way will be linked to you
.
If any of the questions cause you distress or concern, please call 1-314-645-6840 to speak with someone immediately. Outside of normal business hours, call 988.
Drinking alcohol and/or using recreational drugs (including prescription drugs) can affect your health and well-being. These questions concern your possible involvement with alcohol and/or other drugs during the past 6 months. Carefully read each statement and mark the response that best fits for you.
In this questionnaire, (1) the use of prescribed or over the counter drugs differently than the directions given and (2) any non-medical use of drugs. The word “drugs” refers to prescribed or over‐the‐counter medications/drugs in excess of the directions and any non‐medical use of drugs. The various classes of drugs may include (but are not limited to):
Nicotine (e.g., smoking, vaping, nicotine packets)
Cannabis (e.g., marijuana, hash)
Solvents (e.g., gasoline, aerosol agents)
Opioids (e.g., morphine, heroin, fentanyl)
Tranquilizers and Sleep Medications
Barbiturates
Cocaine or other stimulants (e.g., speed, meth)
Hallucinogens (e.g., LSD, PCP)
Combinations of the above substances
I am concerned about...?
Myself
Loved One
2.
I'm concerned about my use of
Alcohol
Recreational drugs
Other (please specify)
3.
Have you felt that you used too much alcohol or other drugs?
Yes
No
4.
Do you feel that you have a drinking or drug problem now?
Yes
No
5.
Have you tried to cut down or quit drinking or using alcohol or other drugs?
Yes
No
6.
Has drinking or other drug use caused problems between you and y our family or friends?
Yes
No
7.
Has your drinking or other drug use caused problems at school or at work?
Yes
No
8.
Have you lost your temper or gotten into arguements or fights while drinking or using other drugs?
Yes
No
9.
Are you needing to drink or use drugs more and more to get the effect you want?
Yes
No
10.
Do you spend a lotof time thinking about or trying to get alcohol or other drugs?
Yes
No
11.
When drinking or using drugs, are you more likely to do something you wouldn't normally do, such as break rules, break the law, sell things that are important to you, or have sex with someone?
Yes
No
12.
Have you had any health problems associated with alcohol use or drug use or misuse?
For example, have you:
Had blackouts or other periods of memory loss?
Yes
No
13.
Injured yourself after drinking or using drugs?
Yes
No
14.
Had seizures, convulsions, or delirium tremons ("DTs")
Yes
No
15.
Had Hepatits or other liver problems?
Yes
No
16.
Felt sick, shakey, or depressed when you stopped?
Yes
No
17.
Felt a crawling feeling under the skin after you stopped using drugs?
Yes
No
18.
Did you answer
Yes
to any of the above questions?
Getting a professional assessment is the best way to assess the problem and determine what types of services might be right for you.
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1430 Olive Street St. Louis, MO 63103
Yes
No
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