*The CRAFFT Questionnaire (version 2.1)

Please answer all questions honestly; your answers will be kept confidential.
Full Name:*
D.O.B*

MonthDayYear
MM/DD/YYYY
Date*

MonthDayYear
MM/DD/YYYY
Email*
example@example.com
Phone Number*

Area CodePhone Number
During the PAST 12 MONTHS, on how many days did you:
1. Drink more than a few sips of beer, wine, or any drinkcontaining alcohol? Put “0” if none.*
# of days
2. Use any marijuana (weed, oil, or hash, by smoking, vaping,or in food) or “synthetic marijuana” (like “K2,” “Spice”) or“vaping” THC oil? 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, or vape )? Put “0” if none.*
# of days
READ THESE INSTRUCTIONS BEFORE CONTINUING:
- If you put “0” in ALL of the boxes above, ANSWER QUESTION 4, THEN STOP.
- If you put “1” or higher in ANY of the boxes above, ANSWER QUESTIONS 4-9.
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
Should be Empty: