1. In your LIFETIME, which of the following substances have you ever used?

a. Cannabis (marijuana, pot, grass, hash, etc.)

b. Cocaine (coke, crack, etc.)

c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

d. Methamphetamine (speed, crystal meth, ice, etc.)

e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)

g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

h. Street opioids (heroin, opium, etc.)

i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)

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.)

b. Cocaine (coke, crack, etc.)

c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

d. Methamphetamine (speed, crystal meth, ice, etc.)

e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)

g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

h. Street opioids (heroin, opium, etc.)

i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)

Other from 1.j. (if NO other, LEAVE BLANK)

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.)

b. Cocaine (coke, crack, etc.)

c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

d. Methamphetamine (speed, crystal meth, ice, etc.)

e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)

g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

h. Street opioids (heroin, opium, etc.)

i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)

Other from 1.j. (if NO other, LEAVE BLANK)

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.)

b. Cocaine (coke, crack, etc.)

c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

d. Methamphetamine (speed, crystal meth, ice, etc.)

e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)

g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

h. Street opioids (heroin, opium, etc.)

i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)

Other from 1.j. (if NO other, LEAVE BLANK)

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.)

b. Cocaine (coke, crack, etc.)

c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

d. Methamphetamine (speed, crystal meth, ice, etc.)

e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)

g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

h. Street opioids (heroin, opium, etc.)

i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)

j. Other from 1.j. (if NO other, LEAVE BLANK)

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.)

b. Cocaine (coke, crack, etc.)

c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

d. Methamphetamine (speed, crystal meth, ice, etc.)

e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)

g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

h. Street opioids (heroin, opium, etc.)

i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)

j. Other from 1.j. (if NO other, LEAVE BLANK)

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.)

b. Cocaine (coke, crack, etc.)

c. Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)

d. Methamphetamine (speed, crystal meth, ice, etc.)

e. Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)

f. Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)

g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)

h. Street opioids (heroin, opium, etc.)

i. Prescription opioids (fentanyl, oxycodone [OxyCotin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)

j. Other from 1.j. (if NO other, LEAVE BLANK)

8. Have you ever used any drug by injection (NONMEDICAL USE ONLY)?