Recognizing Substance Use Disorder

Please circle a number at the end of each question.

Question

Has the patient developed withdrawl symptoms, which can be relieved by tak ing more of the drug?

Has the patient had changes in their daily activity?

Find the sum of the numbers for each question. If the patient has a score of 15 or more, this is a time to have a fur ther conversation with the patient.

Has the patient recognized changes in their eating and/or sleeping habits?

Has the patient had “blackouts” or “ ashbacks” as a result of tak ing a prescription drug?

Does the patient ever feel bad or guilty about their drug use?

O ther areas of strength:

Suggestions for improvements: