Name
Date
2. In the past 30 days, how many nights did you have trouble falling asleep or staying asleep?
3. In the past 30 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day?
4. In the past 30 days, how many days did you drink ANY alcohol? (If 00, Skip to #6)
5. In the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)? [One drink is considered one shot of hard liquor (1.5 oz.) or 12-ounce can/bottle of beer or 5-ounce glass of wine.]
6. In the past 30 days, how many days did you use any illegal or street drugs or abuse any prescription medications? (If 00, Skip to #8)
7A. Marijuana (cannabis, pot, weed)?
7B. Sedatives and/or Tranquilizers (benzos, Valium, Xanax, Ativan, Ambien, barbs, Phenobarbital, downers, etc.)?
7C. Cocaine and/or Crack?
7D. Other Stimulants (amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, speed, crystal meth, ice, etc.)?
7E. Opiates (Heroin, Morphine, Dilaudid, Demerol, Oxycontin, oxy, codeine (Tylenol 2,3,4), Percocet, Vicodin, Fentanyl, etc.)?
7G. Other drugs (steroids, non-prescription sleep and diet pills, Benadryl, Ephedra, other over-the-counter or unknown medications)?
7F. Inhalants (glues, adhesives, nail polish remover, paint thinner, etc.)
10. In the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery?
11. In the past 30 days, how many days were you in any situations or with any people that might put you at an increased risk for using alcohol or drugs (i.e., around risky “people, places or things”)?
13. In the past 30 days, how many days did you spend much of the time at work, school, or doing volunteer work?
14. Do you have enough income (from legal sources) to pay for necessities such as housing, transportation, food and clothing for yourself and your dependents
No (0) Yes (30)
16. In the past 30 days, how many days did you contact or spend time with any family members or friends who are supportive of your recovery?
If you are human, leave this field blank.
SUBMIT
