Substance Abuse Questionnaire Substance Abuse Questionnaire * Input number based on your choices: Not at all - 0, Several days - 1 First Name Last Name Phone (###) ### #### Email * What triggers your addiction? * 1. Have you used drugs other than those required for medical reasons? 0 1 2. Do you abuse more than one drug at a time? 0 1 3. Are you always able to stop using drugs when you want to? (If never use drugs, answer “Yes.”) 0 1 4. Have you had "blackouts" or "flashbacks" as a result of drug use? 0 1 5. Do you ever feel bad or guilty about your drug use? If never use drugs, choose “No.”) 0 1 6. Does your spouse (or parents) ever complain about your involvement with drugs? 0 1 7. Have you neglected your family because of your use of drugs? 0 1 8. Have you engaged in illegal activities in order to obtain drugs? 0 1 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 0 1 10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? 0 1 Thank you!
