Mid School (Name)
________________________________
2.
High School (Name) _______________________________
3.
Not in School ___________________
4.
Other School (Name) ______________________________
5.
Last grade completed: __ __
6.
When _ _ / _ _ / _ _
7.
Employment status:
1.
Full-time ______
2.
Part-time ______
3.
Not working for pay _____
B. Problem Oriented Screening Instrument
for Teenagers
INSTRUCTIONS
The purpose of these questions is to
help us choose the best ways to help you. So, please try to answer the questions honestly.
Please answerall of the questions. If a question does not fit you exactly, pick
the answer that ismostly true. You may see the same or similar questions more than
once. Dont worry about this. This was done on purpose to increase the usefulness of
the instrument. Please just answer each question as it comes up. If you do not understand
a word, please ask for help.
Please click on your answer.
1.
Do you have so much energy you dont know what to do
with it? . . . . . . . . .
Do any of your best friends go out on school nights without
permission from their parents or guardians? . . . . . . . . . . . . . . . . . . . . . . .
. . .
Yes
No
63.
Have you ever had or do you now have a job? . . . . . . . .
. . . . . . . .
Yes
No
64.
Do you have trouble getting your mind off things? . . . . .
. . . . . . . . .
Yes
No
65.
Have you ever threatened anyone with a weapon? . . . . . . .
. . . . . . .
Yes
No
66.
Do you have a way to get to a job? . . . . . . . . . . . . .
. . . . . . .
Yes
No
67.
Do you ever leave a party because there is no alcohol or
drugs? . . . . . . . . .
Yes
No
68.
Do your parents or guardians know what you really think or
feel? . . . . . . . .
Yes
No
69.
Do you often act on the spur of the moment? . . . . . . . .
. . . . . . . .
Yes
No
70.
Do you usually exercise for a half-hour or more at least
once a week? . . . . . .
Yes
No
71.
Do you have a constant desire for alcohol or drugs? . . . .
. . . . . . . . .
Yes
No
72.
Is it easy to learn new things? . . . . . . . . . . . . . .
. . . . . . . . .
Yes
No
73.
Do you have trouble with your breathing or with coughing? .
. . . . . . . . .
Yes
No
74.
Do people your own age like and respect you? . . . . . . . .
. . . . . . . .
Yes
No
75.
Does your mind wander a lot? . . . . . . . . . . . . . . . .
. . . . . .
Yes
No
76.
Do you hear things no one else around you hears? . . . . . .
. . . . . . . . .
Yes
No
77.
Do you have trouble concentrating? . . . . . . . . . . . . .
. . . . . . .
Yes
No
78.
Do you have a valid drivers license? . . . . . . . . .
. . . . . . . . . . .
Yes
No
79.
Have you ever had a paying job that lasted at least one
month? . . . . . . . . . .
Yes
No
80.
Do you and your parents or guardians have frequent arguments
which involve yelling and screaming? . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Yes
No
81.
Have you had a car accident while high on alcohol or drugs?
. . . . . . . . . .
Yes
No
82.
Do you forget things you did while drinking or using drugs?
. . . . . . . . . .
Yes
No
83.
During the past month have you driven a car while you were
drunk or high? . . . .
Yes
No
84.
Are you louder than other kids? . . . . . . . . . . . . . .
. . . . . . .
Yes
No
85.
Are most of your friends younger than you are? . . . . . . .
. . . . . . . .
Yes
No
86.
Have you ever intentionally damaged someone elses
property? . . . . . . . . .
Yes
No
87.
Have you ever stopped working at a job because you just
didnt care? . . . . . . .
Yes
No
88.
Do your parents or guardians like talking with you and being
with you? . . . . . .
Yes
No
90.
Have you ever spent the night away from home when your
parents didnt know where you were? . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . .
Yes
No
91.
Have any of your best friends participated in team sports
which require regular practices? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .
Yes
No
92.
Are you suspicious of other people? . . . . . . . . . . . .
. . . . . . . .
Yes
No
93.
Are you already too busy with school and other adult
supervised activities to be interested in a job? . . . . . . . . . . . . . . . . . . . . .
. . . . . .
Yes
No
94.
Have you cut school at least 5 days in the past year? . . .
. . . . . . . . . . .
Yes
No
95.
Are you usually pleased with how well you do in activities
with your friends? . . .
Yes
No
96.
Does alcohol or drug use cause your moods to change quickly
like from happy to sad or vice versa? . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . .
Yes
No
97.
Do you feel sad most of the time? . . . . . . . . . . . . .
. . . . . . . .
Yes
No
98.
Do you miss school or arrive late for school because of your
alcohol or drug use?
Yes
No
99.
Is it important to you now to get or keep a satisfactory
job? . . . . . . . . . . .
Yes
No
100.
Do your family or friends ever tell you that you should cut
down on your drinking or drug use? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . .
Yes
No
101.
Do you have serious arguments with friends or family members
because of your drinking or drug use? . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
102.
Do you tease others a lot? . . . . . . . . . . . . . . . . .
. . . . . . .
Yes
No
103.
Do you have trouble sleeping? . . . . . . . . . . . . . . .
. . . . . . .
Yes
No
104.
Do you have trouble with written work? . . . . . . . . . . .
. . . . . . . .
Yes
No
105.
Does your alcohol or drug use ever make you do something you
would not normally do like breaking rules, missing curfew, breaking the law or
having sex with someone? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
106.
Do you feel you lose control and get into fights? . . . . .
. . . . . . . . . .
Yes
No
107.
Have you ever been fired from a job? . . . . . . . . . . . .
. . . . . . .
Yes
No
108.
During the past month, have you skipped school? . . . . . .
. . . . . . . . .
Yes
No
109.
Do you have trouble getting along with any of your friends
because of your alcohol or drug use? . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . .
Yes
No
110.
Do you have a hard time following directions? . . . . . . .
. . . . . . . . .
Yes
No
111.
Are you good at talking your way out of trouble? . . . . . .
. . . . . . . . .
Yes
No
112.
Do you have friends who have hit or threatened to hit
someone without any real reason? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .
Yes
No
113.
Do you ever feel you cant control your alcohol or drug
use? . . . . . . . . . .
Yes
No
114.
Do you have a good memory? . . . . . . . . . . . . . . . . .
. . . . .
Yes
No
115.
Do your parents or guardians have a pretty good idea of your
interests? . . . . . .
Yes
No
116.
Do your parents or guardians usually agree about how to
handle you? . . . . . . .
Yes
No
117.
Do you have a hard time planning and organizing? . . . . . .
. . . . . . . .
Yes
No
118.
Do you have trouble with math? . . . . . . . . . . . . . . .
. . . . . .
Yes
No
119.
Do your friends cut school a lot? . . . . . . . . . . . . .
. . . . . . . .
Have you ever had sexual intercourse without using a condom?
. . . . . . . . .
Yes
No
C. Smoking and Family History.
Please fill in or circle your answer.
Do you smoke cigarettes?
Yes, daily or almost daily.
How many cigarettes did you smoke per day in the past 30
days? Number or cigarettes per day (not packs) _____? (NOTE: one pack=20 cigarettes)
Yes, occasionally.
Number of cigarettes smoked in the past month: ____ (not
packs) (NOTE: one pack=20 cigarettes)
No (Skip to question
4.)
Do you think you smoke too
much?
Strongly Disagree
Disagree
Unsure
Agree
Strongly Agree
Are you trying to smoke less than you used to?
Not at all
No
Not sure
Yes
Yes, very much
Do you use other tobacco products such as chewing
tobacco?
Yes
No
Number of brothers: _____
Number of brothers with alcohol or drug problems: ____
Number of sisters: _____
Number of sisters with alcohol or drug problems: ____
Birth order: ("1" if you are the
oldest,"2" if second oldest, etc.)_____
RESIDENCE: (mark with whom you live the most):
Parents
One parent and a stepparent
One parent only
Other family members (grandparents, aunts, uncles, etc.)
Friends or alone
Have any of your relatives had what you would call a
significant drinking or drug use problem one that did or should have led to
treatment? Please put a check in box if "yes". If you dont know, leave
blank. Alcohol / Drug /Mother
/ Father
/ Mothers father
/ Fathers father
/ Mothers mother
/ Fathers mother
D. Use of Alcohol
Alcohol includes beer, wine, hard
liquor and mixed drinks.
Please click on your answer about your use of alcohol.
In the past 30 days, how often did you
have a drink containing alcohol?
Never.
Monthly or less.
2 to 4 times a month.
2 to 3 times a week.
4 or more times a week.
In the past 30 days, how many drinks containing alcohol
did you have on a typical day when you were drinking?
1 or 2.
3 or 4.
5 or 6.
7 to 9.
10 or more standard drinks.
In the past 30 days, how often did you have six or more
drinks on one occasion?
Never.
Less than monthly.
Monthly.
Weekly.
Daily or almost daily.
In the past year, how often did you find that you were
not able to stop drinking once you had started?
Never.
Less than monthly.
Monthly.
Weekly.
Daily or almost daily.
In the past year, how often have you failed to do what
was normally expected from you because of drinking?
Never.
Less than monthly.
Monthly.
Weekly.
Daily or almost daily.
How often during the past year have you needed a first
drink in the morning to get yourself going after a heavy drinking session?
Never.
Less than monthly.
Monthly.
Weekly.
Daily or almost daily.
How often during the past year have you had a feeling of
guilt or remorse after drinking?
Never.
Less than monthly.
Monthly.
Weekly.
Daily or almost daily.
How often during the past year have you been unable to
remember what happened the night before because you had been drinking?
Never.
Less than monthly.
Monthly.
Weekly.
Daily or almost daily.
Have you or someone else ever been
injured as a result of your drinking?
No.
Yes, but not in the past year.
Yes, during the past year.
Has a relative, friend, doctor, or
other health worker been concerned about your drinking or suggested you cut down?
No.
Yes, but not in the past year.
Yes, during the past year.
E. Alcohol and Other Drugs
Below is a list of several kinds of
drugs that people use. Please click on the answer that best describes your use
of these drugs. If you have never used the drug, then click
on the letter "A" for NEVER. For alcohol, it is the number of times in your
lifetime that you have been drunk. For all other drugs, it is the number of times in your
lifetime that you used the drug.
A. How many times have you ever been intoxicated or drunk
on alcohol (beer, wine, hard liquor or mixed drinks)?
Never used (skip
to question 2A)
1-10 times
11-25 times
26-50 times
More than 50 times
B. When is the last time you drank alcohol?
More than 1 year ago
(skip to question 2A)
7-12 months ago
(skip to question 2A)
1-6 months ago
(skip to question 2A)
Used in the past 30 days
C. If used in the past 30 days, how many times? __ __
A. How many times have you ever used
amphetamines/stimulants (speed, uppers, bennies, diet pills, crystal, crank, black
beauties, white crosses, pep pills)?
Never used (skip to question 5A)
1-10 times
11-25 times
26-50 times
More than 50 times
B. When is the last time you used
amphetamines/stimulants (speed, uppers, bennies, diet pills, crystal, crank, black
beauties, white crosses, pep pills)?
More than 1 year ago (skip to
question 5A)
7-12 months ago (skip to question
5A)
1-6 months ago (skip to question
5A)
Used in the past 30 days
C. If used in the past 30 days, how
many times? __ __
A. How many times have you ever used hallucinogens
(LSD,
acid, peyote, mushrooms, mescaline, PCP, angel dust)?
Never used (skip to question 6A)
1-10 times
11-25 times
26-50 times
More than 50 times
B. When is the last time you used hallucinogens (LSD,
acid, peyote, mushrooms, mescaline, PCP, angel dust)?
More than 1 year ago (skip to
question 6A)
7-12 months ago (skip to question
6A)
1-6 months ago (skip to question
6A)
Used in the past 30 days
C. If used in the past 30 days, how many times? __ __
A. How many times have you ever used inhalants
(rush,
gasoline, paint, glue, lighter fluid, nitrous oxide, white-out)?
Never used (skip to question 7A)
1-10 times
11-25 times
26-50 times
More than 50 times
B. When is the last time you used inhalants (rush,
gasoline, paint, glue, lighter fluid, nitrous oxide, white-out)?
More than 1 year ago (skip to
question 7A)
7-12 months ago (skip to question
7A)
1-6 months ago (skip to question
7A)
Used in the past 30 days
C. If used in the past 30 days, how many times? __ __
A. How many times have you ever
used other opiates or
pain killers for nonmedical reasons (codeine, opium, morphine, percodan,
dilaudid, demerol, methadone)?
Never used (skip to question 9A)
1-10 times
11-25 times
26-50 times
More than 50 times
B. When is the last time you used used other opiates or
pain killers for nonmedical reasons (codeine, opium, morphine, percodan,
dilaudid, demerol, methadone)?
More than 1 year ago (skip to
question 9A)
7-12 months ago (skip to question
9A)
1-6 months ago (skip to question
9A)
Used in the past 30 days
C. If used in the past 30 days, how many times? __ __
A. How many times have you ever used
barbiturates/sedatives for nonmedical reasons (seconal, nembutal, amytal,
doriden, quaaludes, dalmane, placidyl, sleeping medicines, blues, reds, yellows,
ludes, etc.)?
Never used (skip to question 10A)
1-10 times
11-25 times
26-50 times
More than 50 times
B. When is the last time you used
barbiturates/sedatives for nonmedical reasons (seconal, nembutal, amytal,
doriden, quaaludes, dalmane, placidyl, sleeping medicines, blues, reds, yellows,
ludes, etc)?
More than 1 year ago (skip to
question 10A)
7-12 months ago (skip to question
10A)
1-6 months ago (skip to question
10A)
Used in the past 30 days
C. If used in the past 30 days, how many times? __ __
A. How many times have you ever used tranquilizers for
nonmedical reasons (librium, valium, ativan, xanax, serax, miltown, equanil,
meprobamate)?
Never used (skip to question 11A)
1-10 times
11-25 times
26-50 times
More than 50 times
B. When is the last time you used tranquilizers for
nonmedical reasons (librium, valium, ativan, xanax, serax, miltown, equanil,
meprobamate)?
More than 1 year ago (skip to
question 11A)
7-12 months ago (skip to question
11A)
1-6 months ago (skip to question
11A)
Used in the past 30 days
C. If used in the past 30 days, how many times? __ __
How many times have you ever used barbiturates/sedatives with a prescription
(seconal, nembutal, amytal, doriden, quaaludes, dalmane, placidyl, sleeping medicines, blues, reds, yellows,
ludes, etc.)?
Never used (skip to question 13)
1-10 times
11-25 times
26-50 times
More than 50 times
How many times have you ever used tranquilizerswith
a prescription (librium, valium, ativa, xanax, serax, miltown, equanil,
meproamate)?
Never used (skip to question 16)
1-10 times
11-25 times
26-50 times
More than 50 times
When was the last time you used any of the pain killers,
sedatives, or tranquilizers in questions 11-13?
More than 1 year ago (skip to
question 16)
7-12 months ago (skip to question
16)
1-6 months ago (skip to question
16)
Used in the past 30 days
If used in the past 30 days, how many times? __ __
What is your favorite drug? (Choose onlyone answer)
Alcohol
Marijuana
Cocaine
Crack
Speed or amphetamines
Heroin
Other (write in) _________________________
Never used
A. Have you ever had counseling
or treatment for your alcohol or drug use?
Yes
No
B. If "yes":
A. Do other family members drink
too much alcohol or use illegal drugs?
Yes
No
B. What is their relationship
to you? (Choose all that apply)
Father
Mother
Sister
Brother
Other family member
LIFE USE QUESTIONS
As a result of using or coming off alcohol or any of the
other previously listed drugs, indicate how often any of the following have ever happened
to you.
Never
1-3 times
4-6 times
7-10 times
More than
10
times
1.
Had a blackout (forgot what you did but were still awake)