• The following questions ask about your drug use (including alcohol) in the past 12 months. Please answer them by marking one circle for each question. If you do not feel comfortable giving an answer to a particular question, you may skip it and move on to the next question.
  If you are an inmate, please refer to the 12-month period immediately before you were locked up; that is, the last time you were in the “free world.”
  Also, alcohol is a drug. Your answers to questions about drug use need to include alcohol use, such as drinking beer.

Did you use larger amounts of drugs or use them for a longer time than you had planned or intended?	Yes No
Did you try to cut down on your drug use but were unable to do it?...............	Yes No
Did you spend a lot of time getting drugs, using them, or recovering from their use?	Yes No
Did you get so high or sick from drugs that it --
-- kept you from doing work, going to school, or caring for children?	Yes No
-- caused an accident or put you or others in danger?	Yes No
Did you spend less time at work, school, or with friends so that you could use drugs?	Yes No
Did your drug use cause --
-- emotional or psychological problems?	Yes No
-- problems with family, friends, work, or police?	Yes No
-- physical health or medical problems?	Yes No
Did you increase the amount of a drug you were taking so that you could get the same effects as before?	Yes No
Did you ever keep taking a drug to avoid withdrawal or keep from getting sick?	Yes No
Did you get sick or have withdrawal when you quit or missed taking a drug?	Yes No

© Copyright 2002 TCU Institute of Behavioral Research, Fort Worth, Texas. All rights reserved.