Drug Screening Questionnaire (DAST)

methamphetamines (speed, crystal)

cannabis (marijuana, pot)

inhalants (paint thinner, aerosol, glue)

tranquilizers (valium)

cocaine

narcotics (heroin, oxycodone, methadone, etc.)

hallucinogens (LSD, mushrooms)

Other...

How often have you used these drugs? Monthly Or Less Weelky Daily Or Almost Daily

1. Have you used drugs other than those required for medical reasons? Yes No

2. Do you abuse more than one drug at a time? Yes No

3. Are you always able to stop using drugs when you want to? Yes No

4. Have you ever had blackouts or flashbacks as a result of drug use? Yes No

5. Do you ever feel bad or guilty about your drug use? Yes No

6. Does your spouse (or parents) ever complain about your involvement with drugs? Yes No

7. Have you neglected your family because of your use of drugs? Yes No

8. Have you engaged in illegal activities in order to obtain drugs? Yes No

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? Yes No

10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? Yes No

Have you ever injected drugs? Never Yes, in the past 90 days Yes, more than 90 days ago

Have you ever been in treatment for substance abuse? Never Currently In the past

Your Report