DRUG ASSESSMENT QUESTIONNAIRE

For

Stimulant Use

 

Check the box before any questions to which you would answer yes.

 

1. Are you using more drugs than you plan to use and do you find that you are enjoying it less? That is, your tolerance is developing and despite not feeling very well, you continue to use.

 

2. Are you experiencing 3 or more of the following physical signs?

Excessive periods of fatigue Itching, scraching, and/or skin lesions 

Sinus problems and nose bleeds Trouble breathing and/or catching your breath

Chest pains or palpitations Decreased appetite or weight loss

Tremors and poor coordination Sleep disturbances, sleepiness, or excessive sleep

 

3. Do you feel apathetic, disinterested, depressed; have you lost the ability to concentrate?

 

4. Do you experience mood swings, irritability, short temperedness, emotional outbursts, rage or excessive sadness, paranoid and/or frantic bizarre behavior?

 

5. As a result of drug use, have you been absent, late, or exhibited inappropriate behavior at work?

 

6. Are family members and friends suggesting that you have a problem with drug use and/or are you lying about your frequency of drug use?

 

If you checked the boxes before two or more of these questions you may have a potentially serious drug problem. Pursue further evaluation with a substance abuse professional.

 

This assessment tool has been adapted from Richard Fields’ copyrighted version of the Cocaine Assessment Questionnaire.