All Rights Reserved. Reproduced with permission. 1. In your LIFETIME, which of the following substances have you ever used?a. Cannabis (marijuana, pot, grass, hash, etc.) Yes No None b. Cocaine (coke, crack, etc.) Yes No None c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) Yes No None d. Methamphetamine (speed, crystal meth, ice, etc.) Yes No None e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) Yes No None f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) Yes No None g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) Yes No None h. Street opioids (heroin, opium, etc.) Yes No None i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) Yes No None Other (specify below; if NO other, LEAVE BELOW BLANK) 2. In the past three (3) months, how often have you used the substances you mentioned (first drug, second drug, etc.)a. Cannabis (marijuana, pot, grass, hash, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None b. Cocaine (coke, crack, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None d. Methamphetamine (speed, crystal meth, ice, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None h. Street opioids (heroin, opium, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None Other from 1.j. (if NO other, LEAVE BLANK) Never Once or Twice Monthly Weekly Daily or Almost Daily None 3. In the past three (3) months, how often have you had a strong desire or urge to use (first drug, second drug, etc.)?a. Cannabis (marijuana, pot, grass, hash, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None b. Cocaine (coke, crack, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None d. Methamphetamine (speed, crystal meth, ice, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None h. Street opioids (heroin, opium, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None Other from 1.j. (if NO other, LEAVE BLANK) Never Once or Twice Monthly Weekly Daily or Almost Daily None 4. During the past three (3) months, how often has your use of (first drug, second drug, etc.) led to health, social, legal or financial problems?a. Cannabis (marijuana, pot, grass, hash, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None b. Cocaine (coke, crack, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None d. Methamphetamine (speed, crystal meth, ice, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None h. Street opioids (heroin, opium, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None Other from 1.j. (if NO other, LEAVE BLANK) Never Once or Twice Monthly Weekly Daily or Almost Daily None 5. During the past three (3) months, how often have you failed to do what was normally expected of you because of your use of (first drug, second drug, etc.)?a. Cannabis (marijuana, pot, grass, hash, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None b. Cocaine (coke, crack, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None d. Methamphetamine (speed, crystal meth, ice, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None h. Street opioids (heroin, opium, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) Never Once or Twice Monthly Weekly Daily or Almost Daily None j. Other from 1.j. (if NO other, LEAVE BLANK) Never Once or Twice Monthly Weekly Daily or Almost Daily None 6. Has a friend or relative or anyone else EVER expressed concern about your use of (first drug, second drug, etc.)?a. Cannabis (marijuana, pot, grass, hash, etc.) No, never Yes, but not in the past three months Yes, in the past three months None b. Cocaine (coke, crack, etc.) No, never Yes, but not in the past three months Yes, in the past three months None c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) No, never Yes, but not in the past three months Yes, in the past three months None d. Methamphetamine (speed, crystal meth, ice, etc.) No, never Yes, but not in the past three months Yes, in the past three months None e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) No, never Yes, but not in the past three months Yes, in the past three months None f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) No, never Yes, but not in the past three months Yes, in the past three months None g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) No, never Yes, but not in the past three months Yes, in the past three months None h. Street opioids (heroin, opium, etc.) No, never Yes, but not in the past three months Yes, in the past three months None i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) No, never Yes, but not in the past three months Yes, in the past three months None j. Other from 1.j. (if NO other, LEAVE BLANK) No, never Yes, but not in the past three months Yes, in the past three months None 7. Have you ever tried and failed to control, cut down or stop using (first drug, second drug, etc.)?a. Cannabis (marijuana, pot, grass, hash, etc.) No, never Yes, but not in the past three months Yes, in the past three months None b. Cocaine (coke, crack, etc.) No, never Yes, but not in the past three months Yes, in the past three months None c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.) No, never Yes, but not in the past three months Yes, in the past three months None d. Methamphetamine (speed, crystal meth, ice, etc.) No, never Yes, but not in the past three months Yes, in the past three months None e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.) No, never Yes, but not in the past three months Yes, in the past three months None f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.) No, never Yes, but not in the past three months Yes, in the past three months None g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.) No, never Yes, but not in the past three months Yes, in the past three months None h. Street opioids (heroin, opium, etc.) No, never Yes, but not in the past three months Yes, in the past three months None i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.) No, never Yes, but not in the past three months Yes, in the past three months None j. Other from 1.j. (if NO other, LEAVE BLANK) No, never Yes, but not in the past three months Yes, in the past three months None 8. Have you ever used any drug by injection (NONMEDICAL USE ONLY)? No, never Yes, but not in the past three months Yes, in the past three months None Time's up
