Drug Use Questionnaire Name: __________________________________ Date: __________________________ SSN: ____________________________________ Birthdate: ______________________ The following questions concern information about your potential involvement with drugs excluding alcohol and tobacco during the past 12 months. Carefully read each question and decide if your answer is “Yes” or “No” and check the appropriate box beside each question. Please answer every question. If you have difficulty with a question, then choose the response that is mostly right. These questions refer to the past 12 months. Yes No Yes No N/A 1. Have you used drugs other than those required for medical reasons? 2. Do you abuse more than one drug at a time? 3. Are you always able to stop using drugs when you want to? 4. Have you had “blackouts” or “flashbacks” because of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your spouse/partner (or parent) ever complain about your involvement with drugs? 7. Have you neglected your family because of your use of drugs? 8. Have you engaged in illegal activities to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Have you had medical problems because of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? 11. Question at end of survey. 12. Have you ever snorted or smoked any substance besides tobacco? 13. Have you ever injected any substance into your body, for reasons other than medical necessity? 14. Have you ever used a prescription medication in amounts beyond the prescribed dosage? *DAST Score (Agency Use Only) This question refers to the last three years. 11. Have you been convicted of a drug-related offense within the last three years? I certify by my signature below that I have either read this questionnaire or had it read to me, and that I understand all its questions and parts. I further certify that all my answers are true and correct. ___________________________________ ____________________________________ Worker Signature/Date Applicant’s Signature/Date DFA-WVW-DAST-1 (New 10/23/17) Drug Use Questionnaire Scoring Instructions Agency Use Only In these statements, the term “drug abuse” refers to the use of medications at a level that exceeds the instructions, and/or any non-medical use of drugs. Patients receive 1 point for every “yes” answer except for question #3, for which a “no” answer receives 1 point. DAST-10 Score Degree of Problems Related to Drug Abuse Suggested Action 0 No problems reported None at this time 1–2 Low Level None at this time 3–5 Moderate Level Must Drug Test Applicant 6–8 Substantial Level Must Drug Test Applicant 9 – or more Severe Level Must Drug Test Applicant Question 11: A “yes” response to this question requires the applicant to be drug tested. DFA-WVW-DAST-1 (New 10/23/17)