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How often do you take drugs or medication for headaches?
(prescription, street drugs, or over-the-counter drugs) |
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More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
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How often do you take drugs or medication to help you sleep?
(prescription, street drugs, or over-the-counter drugs) |
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More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
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How often do you take drugs that affect your mood or help you relax? (prescription, street drugs, or over-the-counter drugs) |
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More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
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How often do you feel dependent on coffee to start the day or to keep you awake? |
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Often
Sometimes
Seldom
Never
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Has anyone in your family had a problem with alcohol or other drugs? |
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Yes
No
Don't know
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If yes, how many relatives have had a problem with alcohol or other drugs? |
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1 to 2
3 to 5
6 or more
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How often do you understand the long-term and short-term effects of the drugs you take? (prescription, street drugs, or over-the-counter drugs) |
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Always
Usually
Sometimes
Never
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How often do you consider alternatives to drugs that you take? (prescription, street drugs, or over-the-counter drugs) |
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Always
Usually
Sometimes
Never
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Mark all of the substances your close friends have tried or use |
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Alcohol
Tobacco
Marijuana, hash, THC
Amphetamines (uppers)
Cocaine (Inhaled)
Crack cocaine (Smoked)
LSD (acid)
Mushrooms or peyote
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MDMA (adam, ecstasy)
MDA
PCP (angel dust)
Heroin
Opium
Barbiturates (downers)
Inhalants (glue, toluene)
Other
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Mark all the substances you use or have used |
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Alcohol
Tobacco
Marijuana, hash, THC
Amphetamines (uppers)
Cocaine (Inhaled)
Crack cocaine (Smoked)
LSD (acid)
Mushrooms or peyote
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MDMA (adam, ecstasy)
MDA
PCP (angel dust)
Heroin
Opium
Barbiturates (downers)
Inhalants (glue, toluene)
Other
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Do you use or have you used intravenous drugs? |
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Yes
No
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If yes, have you used intravenous drugs in the past fifteen years in which you used an unsterilized needle or shared a needle with someone else? |
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Yes
No
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Have you ever had a bad reaction or side-effect from a prescription, over-the-counter, or street drug? |
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Yes
No
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Has drug or alcohol use ever caused problems in your life? (such as an arrest or jail term, trouble with your family, friends, job or school, your marriage or personal relationships) |
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Yes
No
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Have you ever had a serious drug/alcohol problem or addiction? |
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Yes
No
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If yes, have you in the past, or are you currently receiving help for your drug or alcohol problem? |
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Yes
No
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Have you ever tried to stop drinking or to stop taking drugs? |
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No
Yes, once
Yes, twice
Yes, three to five times
Yes, more than five times
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In a typical week how many drinks do you have? |
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Cocktails
Beers
Glasses of wine or wine coolers
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Do you ever drink or take drugs to feel self-confident or not feel lonely, angry or bored? |
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Yes
No
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Do you hide, lie about, deny or cover up your drinking or drug taking? |
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Yes
No
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Do your drinking or drug use habits follow a pattern? |
|
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Yes
No
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Do you make alcohol or other drugs the center of life or the essence of all pleasurable, relaxing activities? |
|
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Yes
No
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Do you experience dramatic personality changes, either "high" or "low" after drinking or taking drugs? |
|
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Yes
No
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Do you forget what happened or black out while drinking or taking drugs? |
|
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Yes
No
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Do you feel remorseful after drinking or taking drugs? |
|
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Yes
No
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