1. Have you used drugs other than those required for medical reasons? Yes No 2. Do you abuse more than one drug at a time? Yes No 3. Are you always able to stop using the drug when you want to? Yes No 4. Have you had “blackouts” or “flashbacks” as a result of drug use? Yes No 5. Have you neglected work or missed days due to drug use? Yes No 6. Do you ever feel bad or guilty about your drug use? Yes No 7. Does your spouse or loved one ever complain about your involvement with drugs? Yes No 8. Have you neglected your family because of your use of drugs? Yes No 9. Have you engaged in illegal activities in order to obtain drugs? Yes No 10. Have you ever experienced withdrawal symptoms when you stopped taking drugs? Yes No 11. Have you had medical problems as a result of your drug use (e.g., sinus issues, memory loss, hepatitis, convulsions, bleeding etc)? Yes No
