Are you addicted Tobacco, Alcohol, or Drugs?

1. In the PAST 3 MONTHS, did you smoke a cigarette containing tobacco?

a) In the PAST 3 MONTHS, did you usually smoke more than 10 cigarettes each day?

b) In the PAST 3 MONTHS, did you usually smoke within 30 minutes after waking?

2. In the PAST 3 MONTHS, did you have a drink containing alcohol?

a) In the PAST 3 MONTHS, did you have 4 or more drinks (for females) or 5 or more drinks (for males) containing alcohol in a day?

*One standard drink is about 1 small glass of wine (5 oz), 1 beer (12 oz), or 1 single shot of liquor.
b) In the PAST 3 MONTHS, has anyone expressed concern about your drinking?

c) In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop drinking?

3. In the PAST 3 MONTHS, did you use marijuana (hash, weed)?

a) In the PAST 3 MONTHS, have you had a strong desire or urge to use marijuana at least once a week or more often?

b) In the PAST 3 MONTHS, has anyone expressed concern about your use of marijuana?

4. In the PAST 3 MONTHS, did you use cocaine, crack, or methamphetamine (crystal meth)?

a) In the PAST 3 MONTHS, did you use cocaine, crack, or methamphetamine (crystal meth) at least once a week or more often?

b) In the PAST 3 MONTHS, has anyone expressed concern about your use of cocaine, crack, or methamphetamine (crystal meth)?

5. In the PAST 3 MONTHS, did you use heroin?

a) In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop using heroin?

b) In the PAST 3 MONTHS, has anyone expressed concern about your use of heroin?

6. In the PAST 3 MONTHS, did you use a prescription opiate pain reliever (for example, Percocet,Vicodin) not as prescribed or that was not prescribed for you?

a) In the PAST 3 MONTHS, have you tried and failed to control, cut down or stop using an opiate pain reliever?

b) In the PAST 3 MONTHS, has anyone expressed concern about your use of an opiate pain reliever?

7. In the PAST 3 MONTHS, did you use a medication for anxiety or sleep (for example, Xanax, Ativan,or Klonopin) not as prescribed or that was not prescribed for you?

a) In the PAST 3 MONTHS, have you had a strong desire or urge to use medications for anxiety or sleep at least once a week or more often?

b) In the PAST 3 MONTHS, has anyone expressed concern about your use of medication for anxiety or sleep?

8. In the PAST 3 MONTHS, did you use a medication for ADHD (for example, Adderall, Ritalin) not as prescribed or that was not prescribed for you?

a) In the PAST 3 MONTHS, did you use a medication for ADHD (for example, Adderall, Ritalin) at least once a week or more often?

b) In the PAST 3 MONTHS, has anyone expressed concern about your use of a medication for ADHD(for example, Adderall or Ritalin)?

9. In the PAST 3 MONTHS, did you use any other illegal or recreational drug (for example,ecstasy/molly, GHB, poppers, LSD, mushrooms, special K, bath salts, synthetic marijuana ('spice'),whip-its, etc.)?

a) In the PAST 3 MONTHS, did you use these drugs at least once a week or more often?

b) In the PAST 3 MONTHS, has anyone expressed concern about your use of these drugs?