1. How often do you use drugs other than alcohol?
2. How often do you use more than one drug on the same occasion?
3. How many times do you take drugs on a typical day when you use drugs?
4. How often are you influenced heavily by drugs?
Less often than once a month
Daily or almost every day
5. Over the past year, have you felt that your longing for drugs was so strong that you could not resist it?
Less often than once a month
Daily or almost every day
6. Has it happened, over the past year, that you have not been able to stop taking drugs once you started?
Less often than once a month
Daily or almost every day
7. How often over the past year have you taken drugs and then neglected to do something you should have done?
Less often than once a month
Daily or almost every day
8. How often over the past year have you needed to take a drug the morning after heavy drug use the day before?
Less often than once a month
Daily or almost every day
9. How often over the past year have you had guilt feelings or a bad conscience because you used drugs?
Less often than once a month
Daily or almost every day
10. Have you or anyone else been hurt (mentally or physically) because you used drugs?
Yes, but not over the past year
11. Has a relative or a friend, a doctor or a nurse, or anyone else, been worried about your drug use or said to you that you should stop using drugs?
Yes, but not over the past year
The presented answer sheet is not an original form and is not intended for printing or use as a handout.