SimpleScreeningInstrument.docx

Simple Screening Instrument for Substance Abuse Dis s

Figure H-3. Simple Screening Instrument for Substance Abuse Self-Administered Form

During the past 6 months…

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 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.) (yesB)

5. Have you had any of the following?

• Blackouts or other periods of memory loss
Yes

• Injury to your head after drinking or using drugs
No

• Convulsions, or delirium tremens (“DTs”)
No

· • Hepatitis or other liver problems
No

· Feeling sick, shaky, or depressed when you stopped drinking or using drugs
Yes

• Feeling “coke bugs,” or a crawling feeling under the skin, after you stopped using drugs No

• Injury after drinking or using drugs No

• Using needles to shoot drugs No

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 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)

Now I have some questions that are not limited to the past 6 months.

14. Have you ever had a drinking or other drug problem? (yes/no)

15. Have any of your family members ever had a drinking or drug problem? (yes/no)

16. Do you feel that you have a drinking or drug problem now? (yes/no)

• Thanks for answering these questions.

• Do you have any questions for me?

• Is there something I can do to help you?

Notes: ________________________________________

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Thanks for filling out this questionnaire.

Scoring for the Simple Screening Instrument for Substance Abuse

Name/ID No.: ____________________________________ Date: ________________________________
Place/Location: __________________________________________________________________________
Items 1 and 15 are not scored. The following items are scored as 1 (yes) or 0 (no):
___ 2 ___ 7 ___ 12
___ 3 ___ 8 ___ 13
___ 4 ___ 9 ___ 14
___ 5 (any items listed) ___ 10 ___ 16
___ 6 ___ 11
Total score: ____ Score range: 0-14
Preliminary interpretation of responses:
Score Degree of Risk for Substance Abuse
0-1 None to low
2-3 Minimal
>4 Moderate to high: possible need for further assessment.
Adapted from U.S. Department of Health and Human Services. (2005). Substance abuse treatment for persons with co-occurring dis s: A treatment improvement protocol TIP 42 (pp. 509-511). Washington, DC: Author. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64197/pdf/TOC.pdf