SAY: "I'm going to ask you a few questions that I ask all my patients. Please be honest. I will keep your answers confidential."
During the past 12 months, did you...
1. Drink any alcohol (more than a few sips)?

2. Smoke any marijuana or hashish?

3. Use anything else to get high? ("Anything else" includes illegal drugs, over the counter and prescription drugs, and things that you sniff or "huff")

If questions 1-3 were answered "No", skip questions 7-9.

4. Have you ever ridden in a car driven by someone (including yourself) who was "high" or had been using alcohol or drugs?

5. Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?

6. Do you ever use alcohol or drugs while you are by yourself, or alone?

7. Do you ever forget things you did while using alcohol or drugs?

8. Do your family or friends ever tell you that you should cut down on your drinking or drug use?

9. Have you ever gotten into trouble while you were using alcohol or drugs?

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