This questionnaire assesses your potential involvement with drugs, excluding alcohol and tobacco, during the past 12 months.

Please fill out all required fields and click the "Submit" button at the end of the questionnaire. 

Following completion, an email will be sent to you with results and how to follow up.

When the words "drug abuse" are used, they mean the use of prescribed or over-the-counter medications/drugs in excess of the directions and any non-medical use of drugs.

*Drugs do not include alcohol or tobacco in this survey

In the past 12 months...

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

© 2018 Refined Transitions

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