The CRAFFT+N Questionnaire 2022

Please answer all questions honestly; your answers will be kept confidential.

Name:*

First NameLast Name

Gender:*

FemaleMale

Date of Birth:*

Date

Age:*

School:*

Grade Level:*

Today's Date:*

Date

During the PAST 12 MONTHS, on how many days did you:

1. Drink more than a few sips of beer, wine, or any drink containing alcohol? Put "0" if none if none.*

# of days

2. Use any marijuana (cannabis, weed, oil, wax, or hash by smoking, vaping, dabbing, or in edibles) or "synthetic marijuana" (like "K2," "Spice")? Put "0" if none.*

# of days

3. Use anything else to get high (like other illegal drugs, prescription or over-the-counter medications, and things that you sniff, huff, vape, or inject)? Put "0" if none.*

# of days

4. Use a vaping device containing nicotine or flavors (like e-cigarettes, vapes, vape pens, pod mods like JUUL or Puff Bars), cigarettes, hookahs, or other tobacco products? Put "0" if none.*

# of days

READ THESE INSTRUCTIONS BEFORE CONTINUING.

If you put '0' in ALL of the boxes above, ANSWER QUESTION 5, THEN MARK N/A.
If you put '1' or higher in ANY of the boxes above, ANSWER QUESTIONS 5-10

5. Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using alcohol or drugs?*

YesNoN/A

6. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?*

YesNoN/A

7. Do you ever use alcohol or drugs while you are by yourself, or ALONE?*

YesNoN/A

8. Do you ever FORGET things you did while using alcohol or drugs?*

YesNoN/A

9. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?*

YesNoN/A

10. Have you ever gotten into TROUBLE while you were using alcohol or drugs?*

YesNoN/A

Part C
“The following questions ask about your use of any vaping devices containing nicotine and/or flavors, or use of any tobacco products.*”

1. Have you ever tried to QUIT using, but couldn’t?*

YesNoN/A

2. Do you vape or use tobacco NOW because it is really hard to quit?*

YesNoN/A

3. Have you ever felt like you were ADDICTED to vaping or tobacco?*

YesNoN/A

4. Do you ever have strong CRAVINGS to vape or use tobacco?*

YesNoN/A

5. Have you ever felt like you really NEEDED to vape or use tobacco?*

YesNoN/A

6. Is it hard to keep from vaping or using tobacco in PLACES where you are not supposed to, like school?*

YesNoN/A

7. When you HAVEN’T vaped or
used tobacco in a while
(or when you tried to stop using)…

a. did you find it hard to CONCENTRATE because you couldn’t vape or use*

YesNoN/A

b. did you feel more IRRITABLE because you couldn’t vape or use tobacco?*

YesNoN/A

c. did you feel a strong NEED or urge to vape or use tobacco?*

YesNoN/A

d. did you feel NERVOUS, restless, or anxious because you couldn’t vape or use tobacco?*

YesNoN/A

NOTICE TO CLINIC STAFF AND MEDICAL RECORDS:

The information on this pade is protected by special federal confidentiality rules (42 CFR Part 2). which is prohibit disclosure of this information unless authorized by specfic written consent.

John R. Knight, MD, Boaston Children's Hospital, 2020. Reproduced with permission from the Center for Adolescent Substance Use and Addicition Research (CeASAR), Boston Childern's Hospital. For more information and versions in other languages, see www.craft.org