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CRAFFT Questionnaire
To be completed by patient. Please answer all questions honestly; your answers will be kept confidential.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
1. During the PAST 12 MONTHS, on how many days did you drink more than a few sips of beer, wine, or any drink containing alcohol? Put “0” if none.
*
2. During the PAST 12 MONTHS, on how many days did you use any marijuana (pot, weed, hash, or in foods) or “synthetic marijuana” (like “K2,” “Spice”) or “vaping” THC oil? Put “0” if none.
*
3. During the PAST 12 MONTHS, on how many days did you use anything else to get high (like other illegal drugs, prescription or over-the-counter medications, and things that you sniff or “huff”)? Put “0” if none.
*
4. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
*
No
Yes
5. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
*
No
Yes
6. Do you ever use alcohol or drugs while you are by yourself, or ALONE?
*
No
Yes
7. Do you ever FORGET things you did while using alcohol or drugs?
*
No
Yes
8. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
*
No
Yes
9. Have you ever gotten into TROUBLE while you were using alcohol or drugs?
*
No
Yes
Submit
Should be Empty: