Munson Health
 
DRUG USE QUESTIONNAIRE

The following questions ask about your potential involvement with drugs excluding alcohol and tobacco during the past 12 months. Carefully read each question and check "YES" or "NO" beside the question.

When the words "drug abuse" are used, they mean the use of prescribed or over-the-counter medications used in excess of the directions and any non-medical use of any drugs. The various classes of drugs may include but are not limited to: cannabis (e.g. marijuana, hash), solvents (e.g. gas, paints, etc.), tranquilizers (e.g. Valium), barbiturates, cocaine, and stimulants (e.g. speed), hallucinogens (e.g. LSD) or narcotics (e.g. Heroin). Remember that the questions do not include alcohol or tobacco.

Please answer every question. If you have difficulty with a question, choose the response that is mostly right.

  
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Have you used drugs other than those required for medical reasons?
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Do you abuse more than one drug at a time?
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Are you always able to stop using drugs when you want to?
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Have you had “blackouts” or “flashbacks” as a result of drug use?
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Do you ever feel bad or guilty about your drug use?
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Does your spouse (or parent) ever complain about your involvement with drugs?
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Have you neglected your family because of your use of drugs?
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Have you engaged in illegal activities in order to obtain drugs?
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Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
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Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding etc.)?
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Your email:

Scoring and Interpretation

If you answered "Yes" to 3 or more question you may want a private consultation with Munson Behavioral Health Services at 1-800-662-6766 or confidentially request assistance please enter your email and submit this form to be contacted.