| 1 | Have you used drugs/alcohol other than those required for medical purposes? |
| 2 | Have you abused prescription drugs/alcohol? |
| 3 | Do you use more than one drug/alcohol at a time? |
| 4 | Do you use drugs/alcohol more than once a week? |
| 5 | Have you tried to stop using drugs/alcohol and were you not able to do so? |
| 6 | Have you had blackouts or flashbacks as a result of drug/alcohol use? |
| 7 | Do you ever feel bad or guilty about your drug/alcohol use? |
| 8 | Do your parents or friends ever tell you to cut back your drug/alcohol use? |
| 9 | Has drug/alcohol abuse created problems between you and your parents? |
| 10 | Have you lost friends because of your use of drugs/alcohol? |
| 11 | Have you neglected your family because of your use of drugs/alcohol? |
| 12 | Have you been in trouble at school because of your use of drugs/alcohol? |
| 13 | Have you gotten into fights when under the influence of drugs/alcohol? |
| 14 | Have you engaged in illegal activities in order to obtain illegal drugs/alcohol? |
| 15 | Have you been arrested for possession of illegal drugs/alcohol? |
| 16 | Have you ever experienced withdrawal symptoms(felt sick) when you stopped taking drugs/alcohol? |
| 17 | Have you had medical problems as a result of your drugs/alcohol use? |
| 18 | Have you gone to anyone for help for a drug/alcohol problem? |
| 19 | Have you stopped doing things that used to be a big part of your life? (Sports, school work, hanging out with friends who don’t do drugs/alcohol)? |
| 20 | Do you hide drugs or alcohol? |
| 21 | Do you use them alone? |
According to the Vanderbilt University Addiction Centre (Treatment Centre) a person needs help if they answer Yes at the following rates:
| 1 – 5 | Low level of concern |
| 6 -10 | Further consulting / Education is needed |
| 11 – 15 | Substantial problem – treatment is needed |
| 16 – 21 | Severe problem – treatment is needed |
