BHRCS: Behavioral Health Research: Y-STOP Screening Form

Y-STOP!

YOUTH SCREENING AND TREATMENT OPPORTUNITIES PROGRAM

Participant Information Sheet

To be completed by Screener/Counselor

Date: __ __ /__ __ /__ __
Mo day year
Name: __________________________________________________________
First Middle Last
Address: _______________________________________________________

_______________________________________________________________
           City State Zip
D.O.B.: __ __ /__ __ /__ __
Mo day year
Telephone: ( __ __ __ ) __ __ __ - __ __ __ __
S.S.N.: __ __ __ - __ __ - __ __ __ __
Age at this arrest (give age in years): __ __
Reason for this arrest or summons (check all that apply):

1.	Marijuana possession ____	8.	Marijuana distribution ____
2.	Alcohol possession ____	9.	Other drug possession ____
3.	Driving while impaired ____	10.	Other drug distribution ____
4.	Alcohol possession in vehicle ____	11.	Shoplifting ____
5	Narcotics possession ____	12.	Domestic violence ____
6.	Narcotics distribution ____	13.	Truancy ____
7.	Other _______________________________________

Probation Officer: ____________________________________________
First Last
What other offenses have you been arrested for? (Use back of form if you need more room):

Offense Age Disposition (outcome)

______________________ ____ ______________________________________________________

How many DWI arrests ever:

1.	None ____
2.	One prior ____
3	Two or more prior _____
4	Unknown

Y-STOP!

YOUTH SCREENING AND TREATMENT OPPORTUNITIES PROGRAM

A. Participant Information Sheet
To be completed by Youth

START TIME: __________

Gender:

1.	Male ____
2.	Female _____

Current Age: __ __
Ethnicity (check all that apply):

1.	Non-Hispanic white _____
2.	Hispanic _____
3.	Mexican National _____
4.	African American _____
5.	American Indian _____
6.	Asian American _____
7.	Other _______________

Parent or Guardian

Name:_________________________________________________________
First Middle Last

Address: ______________________________________________________

______________________________________________________
City State Zip

Telephone: Home: ( __ __ __ ) __ __ __ - __ __ __ __
Work: ( __ __ __ ) __ __ __ - __ __ __ __

School attending:

1.	Mid School (Name) ________________________________
2.	High School (Name) _______________________________
3.	Not in School ___________________
4.	Other School (Name) ______________________________

Last grade completed: __ __

When _ _ / _ _ / _ _

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. Don’t 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 don’t know what to do with it? . . . . . . . . .	Yes	No
2.	Do you brag? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
3.	Do you get into trouble because you use drugs or alcohol at school? . . . . . . .	Yes	No
4.	Do your friends get bored at parties when there is no alcohol served? . . . . . . .	Yes	No
5.	Is it hard for you to ask for help from others? . . . . . . . . . . . . . . . . .	Yes	No
6.	Has there been adult supervision at the parties you have gone to recently? . . . . .	Yes	No
7.	Do your parents or guardians argue a lot? . . . . . . . . . . . . . . . . . .	Yes	No
8.	Do you usually think about how your actions will affect others? . . . . . . . . .	Yes	No
9.	Have you recently either lost or gained more than 10 pounds? . . . . . . . . . .	Yes	No
10.	Have you ever had sex with someone who shot up drugs? . . . . . . . . . . . .	Yes	No
11.	Do you often feel tired? . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
12.	Have you had trouble with stomach pain or nausea? . . . . . . . . . . . . . .	Yes	No
13.	Do you get easily frightened? . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
14.	Have any of your best friends dated regularly during the past year? . . . . . . . .	Yes	No
15.	Have you dated regularly in the past year? . . . . . . . . . . . . . . . . . .	Yes	No
16.	Do you have a skill, craft, trade or work experience? . . . . . . . . . . . . . .	Yes	No
17.	Are most of your friends older than you are? . . . . . . . . . . . . . . . . .	Yes	No
18.	Do you have less energy than you think you should? . . . . . . . . . . . . . .	Yes	No
19.	Do you get frustrated easily? . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
20.	Do you threaten to hurt people? . . . . . . . . . . . . . . . . . . . . . .	Yes	No
21.	Do you feel alone most of the time? . . . . . . . . . . . . . . . . . . . .	Yes	No
22.	Do you sleep either too much or too little? . . . . . . . . . . . . . . . . . .	Yes	No
23.	Do you swear or use dirty language? . . . . . . . . . . . . . . . . . . . .	Yes	No
24.	Are you a good listener? . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
25.	Do your parents or guardians approve of your friends? . . . . . . . . . . . . .	Yes	No
26.	Have you lied to anyone in the past week?. . . . . . . . . . . . . . . . . . .	Yes	No
27.	Do your parents or guardians refuse to talk with you when they are mad at you? . . .	Yes	No
28.	Do you rush into things without thinking about what could happen? . . . . . . .	Yes	No
29.	Did you have a paying job last summer? . . . . . . . . . . . . . . . . . .	Yes	No
30.	Is your free time spent just hanging out with friends? . . . . . . . . . . . . .	Yes	No
31.	Have you accidentally hurt yourself or someone else while high on alcohol or drugs?	Yes	No
32.	Have you had any accidents or injuries that still bother you? . . . . . . . . . .	Yes	No
33.	Are you a good speller? . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
34.	Do you have friends who damage or destroy things on purpose? . . . . . . . . .	Yes	No
35.	Have the whites of your eyes ever turned yellow? . . . . . . . . . . . . . . .	Yes	No
36.	Do your parents or guardians usually know where you are and what you are doing?	Yes	No
37.	Do you miss out on activities because you spend too much money on drugs or alcohol? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
38.	Do people pick on you because of the way you look? . . . . . . . . . . . . .	Yes	No
39.	Do you know how to get a job if you want one? . . . . . . . . . . . . . . .	Yes	No
40.	Do your parents or guardians and you do lots of things together? . . . . . . . .	Yes	No
41.	Do you get A’s and B’s in some classes and fail others? . . . . . . . . . . . .	Yes	No
42.	Do you feel nervous most of the time? . . . . . . . . . . . . . . . . . . .	Yes	No
43.	Have you stolen things? . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
44.	Have you ever been told you are hyperactive? . . . . . . . . . . . . . . . .	Yes	No
45.	Do you ever feel you are addicted to alcohol or drugs? . . . . . . . . . . . . .	Yes	No
46.	Are you a good reader? . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
47.	Do you have a hobby you are really interested in? . . . . . . . . . . . . . .	Yes	No
48.	Do you plan to get a diploma (or already have one)? . . . . . . . . . . . . .	Yes	No
49.	Have you been frequently absent or late for work? . . . . . . . . . . . . . .	Yes	No
50.	Do you feel people are against you? . . . . . . . . . . . . . . . . . . . .	Yes	No
51.	Do you participate in team sports which have regular practice? . . . . . . . . .	Yes	No
52.	Have you ever read a book cover to cover for your own enjoyment? . . . . . . .	Yes	No
53.	Do you have chores that you must regularly do at home? . . . . . . . . . . . .	Yes	No
54.	Do your friends bring drugs to parties? . . . . . . . . . . . . . . . . . . .	Yes	No
55.	Do you get into fights a lot? . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
56.	Do you have a hot temper? . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
57.	Do your parents or guardians pay attention when you talk with them? . . . . . .	Yes	No
58.	Have you started using more and more drugs or alcohol to get the effect you want?	Yes	No
59.	Do your parents or guardians have rules about what you can and cannot do? . . . .	Yes	No
60.	Do people tell you that you are careless? . . . . . . . . . . . . . . . . . .	Yes	No
61.	Are you stubborn? . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
62.	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 driver’s 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 else’s property? . . . . . . . . .	Yes	No
87.	Have you ever stopped working at a job because you just didn’t 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 didn’t 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 can’t 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? . . . . . . . . . . . . . . . . . . . . .	Yes	No
120.	Do you worry a lot? . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
121.	Do you find it difficult to complete class projects or work tasks? . . . . . . . .	Yes	No
122.	Does school sometimes make you feel stupid? . . . . . . . . . . . . . . . .	Yes	No
123.	Are you able to make friends easily in a new group? . . . . . . . . . . . . . .	Yes	No
124.	Do you often feel like you want to cry? . . . . . . . . . . . . . . . . . . .	Yes	No
125.	Are you afraid to be around people? . . . . . . . . . . . . . . . . . . . .	Yes	No
126.	Do you have friends who have stolen things? . . . . . . . . . . . . . . . . .	Yes	No
127.	Do you want to be a member of any organized group, team, or club? . . . . . . .	Yes	No
128.	Does one of your parents or guardians have a steady job? . . . . . . . . . . . .	Yes	No
129.	Do you think it’s a bad idea to trust other people? . . . . . . . . . . . . . . .	Yes	No
130.	Do you enjoy doing things with people your own age? . . . . . . . . . . . . .	Yes	No
131.	Do you feel you study longer than your classmates and still get poorer grades? . . .	Yes	No
132.	Have you ever failed a grade in school? . . . . . . . . . . . . . . . . . . .	Yes	No
133.	Do you go out for fun on school nights without your parents’ or guardians’ permission? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
134.	Is school hard for you? . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
135.	Do you have an idea about the type of job or career that you want to have? . . . .	Yes	No
136.	On a typical day, do you watch more than two hours of TV? . . . . . . . . . .	Yes	No
137.	Are you restless and can’t sit still? . . . . . . . . . . . . . . . . . . . .	Yes	No
138.	Do you have trouble finding the right words to express what you are thinking? . . .	Yes	No
139.	Do you scream a lot? . . . . . . . . . . . . . . . . . . . . . . . . . .	Yes	No
140.	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 ever smoke a pipe or cigars?
Yes
No
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 don’t know, leave blank.
Alcohol / Drug
/Mother
/ Father
/ Mother’s father
/ Father’s father
/ Mother’s mother
/ Father’s 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 marijuana (pot, hashish, hash, THC)?
   Never used (skip to question 3A)
   1-10 times
   11-25 times
   26-50 times
   More than 50 times
B. When is the last time you used marijuana (pot, hashish, hash, THC)?
    More than 1 year ago (skip to question 3A)
   7-12 months ago (skip to question 3A)
   1-6 months ago (skip to question 3A)
   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 cocaine (coke, snow, crack, rock, blow)?
    Never used (skip to question 4A)
    1-10 times
    11-25 times
    26-50 times
    More than 50 times
B. When is the last time you used cocaine (coke, snow, crack, rock, blow)?
    More than 1 year ago (skip to question 4A)
    7-12 months ago (skip to question 4A)
    1-6 months ago (skip to question 4A)
    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 heroin (horse, H, smack, Junk)?
    Never used (skip to question 8A)
    1-10 times
    11-25 times
    26-50 times
    More than 50 times
B. When is the last time you used heroin (horse, H, smack, Junk)?
    More than 1 year ago (skip to question 8A)
    7-12 months ago (skip to question 8A)
    1-6 months ago (skip to question 8A)
    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 other opiates or pain killerswith a prescription (codeine, opium, morphine, percodan, dilaudid, demerol, methadone)?
    Never used (skip to question 12)
    1-10 times
    11-25 times
    26-50 times
    More than 50 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":
Where: _______________________________________________________________________

When: _______________________________________________________________________
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)	A	B	C	D	E
2.	Became physically violent	A	B	C	D	E
3.	Staggered and stumbled around	A	B	C	D	E
4.	Passed out (became unconscious)	A	B	C	D	E
5.	Tried to take your own life	A	B	C	D	E
6.	Saw or heard things not there	A	B	C	D	E
7.	Became mentally confused	A	B	C	D	E
8.	Thought people were out to get you	A	B	C	D	E
9.	Had physical shakes or tremors	A	B	C	D	E
10.	Became physically sick or nauseated	A	B	C	D	E
11.	Had a seizure or convulsion	A	B	C	D	E
12.	Had rapid or fast heart beat	A	B	C	D	E
13.	Became very anxious, nervous, or tense	A	B	C	D	E
14.	Was very feverish, hot or sweaty	A	B	C	D	E
15.	Did not eat or sleep	A	B	C	D	E
16.	Was weak, tired, and fatigued	A	B	C	D	E
17.	Unable to go to work or school