Addiction Evaluation Questionnaire Form
Please answer the following questions honestly to help reflect on your substance use and related behaviors. This is an anonymous, non-diagnostic questionnaire.
Which substances have you used in the past 12 months? (Select all that apply)
*
Alcohol
Tobacco or Nicotine
Cannabis/Marijuana
Prescription Medication (non-medical use)
Stimulants (e.g., cocaine, amphetamines)
Opioids (e.g., heroin, fentanyl)
Hallucinogens (e.g., LSD, mushrooms)
Other
How often do you use any of these substances?
*
Never
Monthly or less
2–4 times a month
2–3 times a week
4 or more times a week
Have you ever felt that you should cut down on your substance use?
*
Yes
No
Has anyone expressed concern about your substance use?
*
Yes
No
Do you ever use substances to cope with stress, anxiety, or difficult emotions?
*
Often
Sometimes
Rarely
Never
Have you experienced any negative consequences from your substance use? (Select all that apply)
*
Relationship difficulties
Work or academic problems
Legal or financial issues
Health problems
None of the above
Have you ever tried to stop or reduce your substance use? If so, how successful were you?
*
I have not tried
I tried, but was not successful
I tried and was somewhat successful
I tried and was completely successful
Do you ever find it difficult to control the amount or frequency of your substance use?
*
Often
Sometimes
Rarely
Never
Have you ever missed important obligations (work, school, family) due to substance use?
*
Yes
No
Is there anything else you would like to share about your experiences with substance use?
Submit
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