Worried About Your Alcohol Or Other Drug Use? -

If you are worried about your alcohol or other drug use, you could fill out the no-obligation free test below.

DSM-IV Diagnosis – Alcohol and other Drugs

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The following questions ask about your alcohol and/or other drug use in the past 12 months. Please answer them by selecting a response for each question from the drop-down boxes below.

If you are in prison, please refer to the 12-month period immediately before you were locked up; that is, the last time you were in the “free world.”

Also, alcohol is a drug. Your answers to questions about drug use need to include alcohol use, such as drinking beer or wine.

Admin

Client Reference No *

Date *

During the last 12 months (before being locked up, if applicable) –

Questionnaire

Q1. Did you use larger amounts of alcohol or drugs or use them for a longer time than you planned or intended? *

Q2. Did you try to cut down on your alcohol ordrug use but were unable to do it? *

Q3. Did you spend a lot of time getting alcohol or drugs, using them, or recovering from their use? *

Q4a. Did you get so drunk, high or sick from alcohol or drugs that it kept you from doing work, going to school, or caring for children *

Q4b. Did you get so drunk,high or sick from alcohol or drugs that it caused an accident or put you or others in danger? *

Q5. Did you spend less time at work, school, college, or with friends so that you could use alcohol or drugs? *

Q6a. Did your alcohol or drug use cause emotional or psychological problems? *

6b. Did your alcohol or other drug use cause problems with family, friends, work, or police? *

Q6c. Did your alcohol or drug use cause physical health or medical problems? *

Q7. Did you increase the amount of alcohol or a drug you were taking so that you could get the same effects as before? *

Q8. Did you ever keep drinking alcohol or taking a drug to avoid withdrawal symptoms or keep from getting sick? *

Q9. Did you get sick or have withdrawal symptoms
when you quit or missed drinking alcohol or taking a drug? *

Q10. Which drug, including alcohol, caused the most serious problem? [CHOOSE ONE] *

Question 11: Drug Use in Last Month

How often did you use each type of drug during the last month?

a. Alcohol *

b. Marijuana/Hashish *

c. Hallucinogens/LSD/PCP/ Psychedelics/Mushrooms *

d. Inhalants *

e. Crack/Freebase *

f. Heroin and Cocaine (mixed together as Speedball) *

g. Cocaine (by itself) *

h. Heroin (by itself) *

i. Street Methadone (non-prescription) *

j. Other Opiates/Opium/Morphine/Demerol *

k. Methamphetamines *

l. Amphetamines (other uppers) *

m. Tranquilizers/Barbiturates/Sedatives (downers) *

n. Other (please specify in box below) *

Other drugs used (please specify)

Thank you for completing this questionnaire

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