Substance Use Adult - Manage and overcome addiction with Dr. Raj

Name:

Age:

Date:

If the measure is being completed by an informant, what is your relationship with the individual receiving care?

In a typical week, approximately how much time do you spend with the individual receiving care?

hours/week

Instructions: On the DSM‑5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by “feeling irritated, grouchy, or angry” at a mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box per row.

During the past TWO (2) WEEKS, about how often did you use any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed?

	Not at all	One or two days	Several days	More than half the days	Nearly every day
Painkillers (like Vicodin)
Stimulants (like Ritalin, Adderall)
Sedatives or tranquilizers (like sleeping pills or Valium)
Or drugs like:
Marijuana
Cocaine or crack
Club drugs (like ecstasy)
Hallucinogens (like LSD)
Heroin
Inhalants or solvents (like glue)
Methamphetamine (like speed)