Zoom Issue Tracking

1

Have you used drugs other than those required for medical reasons?* This field is required.

YESNO

2

Do you ever use more than one drug at a time (for example: speedballs, crossfading, drug cocktails)?* This field is required.

YESNO

3

Are you always able to stop using drugs when you want to?* This field is required.

YESNO

4

Do you sometimes struggle to remember what happened when you've been using drugs?* This field is required.

YESNO

5

Do you ever feel bad or guilty about your drug use?* This field is required.

YESNO

6

Do your friends, family, or significant others ever complain about you taking drugs?* This field is required.

YESNO

7

Has your drug use impacted your responsibilities at home or work?* This field is required.

YESNO

8

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?* This field is required.

YESNO

9

Have you had medical problems as a result of your drug use (e.g. hepatitis, convulsions, bleeding, etc.)?* This field is required.

YESNO

10

Total score