Have you used drugs other than those required for medical reasons? yes no

Have you abused prescription drugs? yes no

Do you abuse more than one drug at a time? yes no

Can you get through the week without using drugs (other than those required for medical reasons)? yes no

Are you always able to stop using drugs when you want to? yes no

Do you abuse drugs on a continuous basis? yes no

Do you try to limit your drug use to certain situations? yes no

Have you had blackouts or flashbacks as a result of drug use? yes no

Do you ever feel bad about your drug abuse? yes no

Does your spouse (or do your parents) ever complain about your involvement with drugs? yes no

Do your friends or relatives know or suspect you abuse drugs? yes no

Has drug abuse ever created problems between you and your spouse (or significant other)? yes no

Has any family member ever sought help for problems related to your drug use? yes no

Have you ever lost friends because of your use of drugs? yes no

Have you ever neglected your family or missed work because of your use of drugs? yes no

Have you ever been in trouble at work because of drug abuse? yes no

Have you ever lost a job because of drug abuse? yes no

Have you gotten into fights when under the influence of drugs? yes no

Have you ever been arrested because of unusual behavior while under the influence of drugs? yes no

Have you engaged in illegal activities to obtain drugs? yes no

Have you ever been arrested for possession of illegal drugs? yes no

Have you ever experienced withdrawal symptoms as a result of heavy drug intake? yes no

Have you had medical problems as a result of your drug use, e.g., memory loss, hepatitis, convulsions or bleeding? yes no

Have you ever gone to anyone for help for a drug problem? yes no

Have you ever been in a hospital for medical problems related to your drug use? yes no

Have you ever been involved in a treatment program specifically related to drug use? yes no

Have you been treated as an outpatient for problems related to drug abuse?
yes no