Access Yourself
Drug self-assessment form with instant individual risk result.
Self Assessment Form
Student Name (optional)
Which of the following drugs have you used in the past year?
methamphetamines (speed, crystal)
cocaine
cannabis (marijuana, pot)
narcotics (heroin, oxycodone, methadone, etc.)
inhalants (paint thinner, aerosol, glue)
hallucinogens (LSD, mushrooms)
tranquilizers (valium)
Other:
How often have you used these drugs?
Monthly or less
Weekly
Daily or almost daily
Answer the following questions
1. Have you used drugs other than those required for medical reasons?
No
Yes
2. Do you abuse more than one drug at a time?
No
Yes
3. Are you unable to stop using drugs when you want to?
No
Yes
4. Have you ever had blackouts or flashbacks as a result of drug use?
No
Yes
5. Do you ever feel bad or guilty about your drug use?
No
Yes
6. Does your spouse (or parents) ever complain about your involvement with drugs?
No
Yes
7. Have you neglected your family because of your use of drugs?
No
Yes
8. Have you engaged in illegal activities in order to obtain drugs?
No
Yes
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
No
Yes
10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?
No
Yes
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
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