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Alcohol And Substance Abuse Mini-Profile
Welcome to the mini-profile on Alcohol and Substance Use. In just minutes, you'll get feedback on your alcohol and substance use profile.

How often do you take drugs or medication for headaches?
(prescription, street drugs, or over-the-counter drugs)
More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
 
How often do you take drugs or medication to help you sleep?
(prescription, street drugs, or over-the-counter drugs)
More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
How often do you take drugs that affect your mood or help you relax?
(prescription, street drugs, or over-the-counter drugs)
More than 4 times per week
2 to 4 times per week
1 time per week
Seldom
Never
 
How often do you feel dependent on coffee to start the day or to keep you awake? Often
Sometimes
Seldom
Never
 
Has anyone in your family had a problem with alcohol or other drugs? Yes
No
Don't know
 
If yes, how many relatives have had a problem with alcohol or other drugs? 1 to 2
3 to 5
6 or more
 
How often do you understand the long-term and short-term effects of the drugs you take?
(prescription, street drugs, or over-the-counter drugs)
Always
Usually
Sometimes
Never
 
How often do you consider alternatives to drugs that you take?
(prescription, street drugs, or over-the-counter drugs)
Always
Usually
Sometimes
Never
 
Mark all of the substances your close friends have tried or use Alcohol
Tobacco
Marijuana, hash, THC
Amphetamines (uppers)
Cocaine (Inhaled)
Crack cocaine (Smoked)
LSD (acid)
Mushrooms or peyote
MDMA (adam, ecstasy)
MDA
PCP (angel dust)
Heroin
Opium
Barbiturates (downers)
Inhalants (glue, toluene)
Other
 
Mark all the substances you use or have used Alcohol
Tobacco
Marijuana, hash, THC
Amphetamines (uppers)
Cocaine (Inhaled)
Crack cocaine (Smoked)
LSD (acid)
Mushrooms or peyote
MDMA (adam, ecstasy)
MDA
PCP (angel dust)
Heroin
Opium
Barbiturates (downers)
Inhalants (glue, toluene)
Other
 
Do you use or have you used intravenous drugs? Yes No
 
If yes, have you used intravenous drugs in the past fifteen years in which you used an unsterilized needle or shared a needle with someone else? Yes No
 
Have you ever had a bad reaction or side-effect from a prescription, over-the-counter, or street drug? Yes No
 
Has drug or alcohol use ever caused problems in your life?
(such as an arrest or jail term, trouble with your family, friends, job or school, your marriage or personal relationships)
Yes No
 
Have you ever had a serious drug/alcohol problem or addiction? Yes No
 
If yes, have you in the past, or are you currently receiving help for your drug or alcohol problem? Yes No
 
Have you ever tried to stop drinking or to stop taking drugs? No
Yes, once
Yes, twice
Yes, three to five times
Yes, more than five times
 
In a typical week how many drinks do you have? Cocktails
Beers
Glasses of wine or wine coolers
 
Do you ever drink or take drugs to feel self-confident or not feel lonely, angry or bored? Yes No
 
Do you hide, lie about, deny or cover up your drinking or drug taking? Yes No
 
Do your drinking or drug use habits follow a pattern? Yes No
 
Do you make alcohol or other drugs the center of life or the essence of all pleasurable, relaxing activities? Yes No
 
Do you experience dramatic personality changes, either "high" or "low" after drinking or taking drugs? Yes No
 
Do you forget what happened or black out while drinking or taking drugs? Yes No
 
Do you feel remorseful after drinking or taking drugs? Yes No
 

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