Required fields are marked * Email *Please enter your email to receive a copy of your results Contact Number * 1.Have you used drugs other than those required for medical reasons? * No Yes 2.Do you abuse more than one drug at a time? * No Yes 3.Are you unable to stop using drugs when you want to? * No Yes 4.Have you ever had blackouts or flashbacks as a result of drug use? * No Yes 5.Do you ever feel bad or guilty about your drug use? * No Yes 6.Does your spouse (or parents) ever complain about your involvement with drugs? * No Yes 7.Have you neglected your family because of your use of drugs? * No Yes 8.Have you engaged in illegal activities in order to obtain drugs? * No Yes 9.Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? * No Yes 10.Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? * No Yes 11.Have you used any of these substances? How often? methamphetamines (speed, crystal), cannabis (marijuana, pot), inhalants (paint thinner, aerosol, glue), tranquilizers (valium), cocaine, narcotics (heroin, oxycodone, methadone, etc.), hallucinogens (LSD, mushrooms) * Monthly or Less Weekly Daily or Almost Daily 12.Have you ever injected drugs? * Never Yes, in the past 90 days Yes, more than 90 days ago 13.Have you ever been in treatment for substance abuse? * Never Currently In the past