1. How often do you use drugs other than alcohol (see list)?
Never
Once a month or less
2-4 times a month
2-3 times a week
4 or more times a week

2. Do you use more than one type of drug on the same occasion?
Never
Once a month or less
2-4 times a month
2-3 times a week
4 times a week and more

3. How many times do you take drugs on a typical day when you use drugs?
0
1-2
3-4
5-6
7 or more

4. How often are you influenced heavily by drugs?
Never
Less often than once a month
Every month
Every week
Daily or almost daily

5. Over the past year, have you felt that your longing for drugs was so strong that you could not resist it?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

6. Has it happened, over the past year, that you have not been able to stop taking drugs once you started?
Never
Less than monthly
Monthly 
Weekly 
Daily or almost daily

7. How often over the past year have you taken drugs and then neglected to do something you should have done?
Never 
Less than monthly
Monthly 
Weekly
Daily or almost daily

8. How often over the past year have you needed to take a drug the morning after heavy drug use the day before??
Never
Less than monthly
Monthly 
Weekly 
Daily or almost daily

9. How often over the past year have you had guilt feelings or a bad conscience because you used drugs?
Never
Less than monthly
Monthly 
Weekly 
Daily or almost daily

10. Have you or anyone else been hurt (mentally or physically) because you used drugs?
No
Yes, but not in the past year 
Yes, during the past year

11. Has a relative or a friend, a doctor or a nurse, or anyone else, been worried about your drug use or said to you that you should stop using drugs?
No
Yes, but not in the past year 
Yes, during the past year