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Welcome to Recoveration

Iowa Solutions, Inc
1045 Sherman Rd
Hiawatha, IA 52233

Online Distance Treatment Communications Services
 

 


Self-Assessment Questionnaire - Substance Abuse

Directions: The questions that follow are about your use of alcohol and other drugs. Your answers will be kept private. Mark the response that best fits for you. Answer the questions in terms of your experiences in the past 6 months. No personally identifiable information is recorded.

1. Have you used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or other opioids, uppers, downers, hallucinogens, or inhalants)
 
Yes No
2. Have you felt that you use too much alcohol or other drugs?
 
Yes No
3. Have you tried to cut down or quit drinking or using alcohol or other drugs?
 
Yes No
4. Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.)
 
Yes No
5. Have you had any health problems? For example, have you:

Had blackouts other periods of memory loss?
Injured your head after drinking or using drugs?
Had convulsions, delirium tremens ("DTs")?
Has hepatitis or other liver problems?
Felt sick, shaky, or depressed when you stopped?
Felt "Coke bugs" or a crawling feeling under the skin when you stopped using drugs?
Been injured after drinking or using?
Used needles to shoot drugs?

 
6. Has drinking or other drug use caused problems between you and your family or friends?
 
Yes No
7. Has your drinking or other drug use caused problems at school or at work?
 
Yes No
8. Have you been arrested or had other legal problems? (Such as bouncing bad checks, driving while intoxicated, theft, or drug possession.)
 
Yes No
9. Have you lost your temper or gotten into arguments or fights while drinking or using other drugs?
 
Yes No
10. Are you needing to drink or use drugs more and more to get the effect you want?
 
Yes No
11. Do you spend a lot of time thinking about or trying to get alcohol or other drugs?
 
Yes No
12. When drinking or using drugs, are you more likely to do something you wouldn’t normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone?
 
Yes No
13. Do you feel bad or guilty about your drinking or drug use?
 
Yes No

The next questions are about your lifetime experiences...
 
15. Have you ever had a drinking or other drug problem?
 
Yes No
16. Have any of your family members ever had a drinking or drug problem?
 
Yes No
17. Do you feel that you have a drinking or drug problem now?
 
Yes No