3 minutes to complete
General eligibility to complete a Drug Use Questionnaire includes being 18 years of age or older, not currently enrolled in any substance abuse treatment program.
Use this templateHave you used drugs other than those used for medical reasons?
Have you abused prescription drugs?
Do you abuse more than one drug at a time?
Can you get through the week without using drugs?
Are you always being able to stop using drugs when you want to?
Have you had "blackouts" or "flashbacks" as a result of drug use?
Do you ever feel bad or guilty about your drug use?
Does your spouse (or parents) ever complain about your involvement with drugs?
Has drug abuse created problems between you are your spouse or your parents?
Have you lost friends because of your use of drugs?
Have you neglected your family because of your use of drugs?
Have you been in trouble at work because of drug abuse?
Have you lost a job because of drug abuse?
Have you gotten into fights when under the influence of drugs?
Have you engaged in illegal activities in order to obtain drugs?
Have you been arrested for possession of illegal drugs?
Have you ever experienced withdrawal symptoms when you stop taking drugs?
Have you had medical problems as a result of drug use (e.g. memory loss, hepatitis, convulsions, bleeding etc)?
Have you gone to anyone for help for a drug problem?
Have you been involved in a treatment program specifically related to drug use?
“BlockSurvey is a simple, effective, and scalable tool for creating surveys for leadership and learning assessment. It's one of this year's best buying choices. Each month, it keeps improving and strives to serve its customers needs.”
Nelson Emilio Personal Branding Strategist“I use BlockSurvey to get feedback about all my activities and events. It is really easy to get started and create my first surveys! Then I could see how easy it was to share them. Now I am thinking to use BlockSurvey also within my creative process as an author in order to listen and engage with my audience, knowing that anonymity provides the most sincere and reliable answers.”
Georgina García-Mauriño Author & Designer 4.8 Star Rating Editor's choice 4.9 Star RatingThis is a 15-item self-report measure that assesses motives for cigarette smoking. Response choices are on a 5-point Likert scale ("not at all true" to "very true"). Adolescents are asked to rate each potential motive for smoking with respect to how true they think it is. There are four subscales for the 15-item measure. These include Social Motives (4 items), Self-enhancement Motives (4 items), Boredom Relief Motives (2 items), and Affect Regulation Motives (5 items).
Stanford Smoking Dependence InventoryThe SDI is a 5-item modified version of the Fagerstrom Tolerance Questionnaire for use with adolescent smokers. Modifications include rescaling items to provide more response options and analyzing daily cigarette consumption separately.
Jacksons Smoking SusceptibilityJackson's Smoking Susceptibility is a scale used to describe the likelihood of a child's (in grade 3 to grade 5) smoking susceptibility in 2 years.
Smoking Consequences QuestionnaireThe Smoking Consequences Questionnaire is a tool used to assess the possible consequences of someone's smoking habits. The questionnaire is designed to help individuals identify areas of their life that may be negatively impacted by their smoking habits.
The Cigarette Dependence ScaleThe Cigarette Dependence Scale (CDS) is a self-report measure used to assess an individual’s level of nicotine dependence on cigarettes. It assesses the intensity of physical and psychological dependence and the frequency of smoking.
Nicotine Dependence Questionnaire For AdolescentsThe Nicotine Dependence Questionnaire for Adolescents (NDSA) contains questions about nicotine dependence in adolescents. It has questions about the intensity and severity of nicotine use in terms of dependence symptoms, such as craving, withdrawal, and tolerance.
Drug Abuse Screening TestThe Drug Abuse Screening Test (DAST) is a 10-question, self-report survey used to detect potential substance abuse. This test is intended to identify any potential use of illicit drugs, as well as the abuse of prescription drugs.
Alcohol Use Disorders Identification TestBecause alcohol use can affect your health and can interfere with certain medication and treatments, it is important that we ask some questions about your use of alcohol.
Drug Use QuestionnaireThe purpose of this questionnaire is to provide a brief, simple, practical but valid method of identifying individuals who are abusing psychoactive drugs. It also yields a quantitative index score of the degree of problems related to drug use and drug misuse.
Am I An Alcoholic TestDrinking casually with friends for fun doesn’t seem alcoholic; the classic picture of an alcoholic is someone whose life is falling apart, doesn’t have a job, or stealing money to drink. But this is not true; someone who looks pretty perfect and functional from the outer can be alcoholic.