Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.

• 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 drugs when you want to?

  Yes No

• 4. Have you had "blackouts" or "flashbacks" as a result of drug use?

  Yes No

• 5. Do you ever feel bad or guilty about your drug use?

  Yes No

• 6. Does your spouse (or parent) ever complain about your involvement with drugs?

  Yes No

• 7. Have you neglected your family because of your use of drugs?

  Yes No

• 8. Have you engaged in illegal activities in order to obtain drugs?

  Yes No

• 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

  Yes No

• 10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc...)?

  Yes No