DRUG USE QUESTIONNAIRE

Client Name *

First Name Last Name

Date *

Date

The following questions concern information about the clients possible involement with drugs not including alcoholic beverages during the past 12 months.

In the statement "drug abuse" refers to (1 or more) the use of prescribed or over the counter drugs may include: cannabis (e.g. marijuana, hash), solvents, tranquililizers (e.g. Valium), barbiturates, cocaine, stimulants (e.g. speed), hallucinogens (e.g. LSD) or narcotics (e.g. heroin). Remember that these questions DO NOT include alcoholic beverages.

Instructions:

Please read each question below, wait for an answer from the client. Select the appropriate answer (Yes, No or N/A) for each question.

If the client has difficulty answering any question, then have them choose the answer that is mostly right.

These questions refer to the past 12 months. *

Yes/No-N/A

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

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

3. Are you always able to stop using drugs when you want to?

4. Have you had "blackouts" or "flashbacks" as a result or drug use?

5. Do you ever feel bad or guilty about your drug use?

6. Does your spouse (or parents) ever complain about your involvement with drugs?

7. Have you neglected your family because of your use of drugs?

8. Have you engaged in illegal activities in order to obtain drugs?

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

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

Copyright 1982 by Harvey A Skinner, PhD and the Centre for Addication and Mental Health, Toronto, Canada. You may reproduce this instrument for non-commercial use (clinical, research, training purposes) as long as you credit the author Hervey A. Skinner, Department of Public Health Sciences, University of Toronto.