Alcohol & Substance Use/Abuse
First Name
Last Name
Student ID
1. Do you regularly use alcohol?
Yes
No
2. Average # of drinks you consume a week?
Never
1-2
3-4
5-more
3. How many times have you had five or more drinks at a sitting?
None
Once
Twice
3 to 5 times
4. At what age did you first use alcohol?
Never drink
under 10
10-12
12-13
14-16
16-18
18+
5. Do you regularly use tobacco?
Yes
No
Never
6. How many times a week have you used tobacco?
Never
1-2
3-4
5-more
8. How many times a week have you used marijuana?
Never
1-2
3-4
5- more times
7. Do you regularly use marijuana?
Never
Yes
No
9. Do you consider your alcohol consumption or other substance use a problem?
Yes
No
IN THE PAST YEAR, HOW MANY TIMES HAVE YOU USED?
10. Prescription drugs that were not prescribed for you ( such as pain medication or Opioids?)
Never
Once or twice
Monthy
Weekly or more
11. Illegal drugs ( such as Cocaine or Ecstasy?)
Never
Once or twice
Monthy
Weekly or more
12. Inhalants (such as Nitrous Oxides?)
Never
Once or twice
Monthy
Weekly or more
13. Herbs or Synthetic drugs ( such as Salvia, "K2", or Bath Salts?)
Never
Once or twice
Monthy
Weekly or more
14. During the past 30 days on how many days did you have? (Mark all that apply/s)
a. Alcohol (Beer, Wines, Liquor)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
b. Tobacco (Smoke, Chew, Snuff)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
c. Marijuana (Pot, Hash, Hash oil)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
d. Cocaine (Crack, Rock, Freebase)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
e. Amphetamine (Diet pills, Speed)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
f. Sedatives (Downers, Ludes)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
g. Hallucinogens (LSD, PCP)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
h. Opiates (Heroin, Smack, Horse)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
i. Inhalants (Glues, Solvents, Gas)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
j. Designers drugs (Ecstasy, MOMA)
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
K. Steroids
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
I. Other Illegal drugs
0
1-2
3-5
6-9
10-19
20-29
All 30 days
Please Specify
* A drink is bottle of beer, a glass of wine, a wine cooler, a shot glass of liquor, or a mixed drink
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