Substance Abuse Self-Assessment Over the last 2 weeks, on how many days have you been bothered by any of the following problems? Phone Question 1 Have you used alcohol or other drugs in the last 6 months (such as wine, beer, hard liquor, pot, cocaine, heroin, or other opioids, uppers, downers, hallucinogens, or inhalants)? Have you used alcohol or other drugs in the last 6 months (such as wine, beer, hard liquor, pot, cocaine, heroin, or other opioids, uppers, downers, hallucinogens, or inhalants)? Yes No Question 2 Have you ever felt the need to cut down on drinking or drug use? Have you ever felt the need to cut down on drinking or drug use? Yes No Question 3 Have you (check all that apply): Have you (check all that apply): Had blackouts or other periods of memory loss? Injured your head after drinking or using drugs? Had convulsions or delirium tremens ("DT"s)? Felt sick, shaky, or depressed when you stopped? Felt "coke bugs" or crawling feeling under the skin after you stopped using drugs? Been injured after drinking or using? Used needles to shoot drugs? Question 4 Has drinking or other drug use caused problems in your social or work life? Has drinking or other drug use caused problems in your social or work life? Yes No Question 5 Have you ever been arrested or had other legal problems? (Such as bouncing bad checks, driving while intoxicated theft, or drug possession.) Have you ever been arrested or had other legal problems? (Such as bouncing bad checks, driving while intoxicated theft, or drug possession.) Yes No Question 6 Have you lost your temper or gotten into arguments or fights while drinking or using other drugs? Have you lost your temper or gotten into arguments or fights while drinking or using other drugs? Yes No Question 7 Do you need to drink or use drugs more and more to get the effect you want? Do you need to drink or use drugs more and more to get the effect you want? Yes No Question 8 Have you ever felt you needed a drink or drug first thing in the morning to steady your nerves or to get rid of a hangover? Do you need to drink or use drugs more and more to get the effect you want? Yes No Question 8 When drinking or using drugs, are you more likely to do something you wouldn't normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone? When drinking or using drugs, are you more likely to do something you wouldn't normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone? Yes No Question 8 Have you ever felt bad or guilty about your drinking or drug use? Have you ever felt bad or guilty about your drinking or drug use? Yes No First Name Last Name Phone Number Email Address
