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Self Assessment Tool

The following questions concern your involvement with drugs and alcohol over the last 12 months.

1. Have you used drugs other than those required for medical reasons?
Yes NO

2. Do you abuse more than one drug at a time, or use drugs and alcohol at the same time?
Yes NO

3. Are you unable to stop using drugs or alcohol when you want to?
Yes NO

4. Have you ever had blackouts or flashbacks as a result of drug or alcohol use?
Yes NO

5. Do you ever feel bad or guilty about your drug or alcohol use?
Yes NO

6. Does your spouse (or parents) ever complain about your drug or alcohol use?
Yes NO

7. Have you neglected your family because of your use of drugs or alcohol?
Yes NO

8. Have you engaged in illegal activities in order to obtain drugs or alcohol?
Yes NO

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs or drinking alcohol?
Yes NO

10. Have you had medical problems as a result of your drug or alcohol use (e.g., memory loss, hepatitis, convulsions, bleeding)?
Yes NO

CoRR | Grass Valley 530-273-9541 | South County 530-268-2356 | Truckee 530-587-8194
Hope House Women's Residential Facility | Phone 530-271-1140

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