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Assess Your Drug Use

Overview

You can complete this form and print it for easy reference. When you exit the form, the information will be deleted.

Answer these questions based on your use of drugs—not alcohol— in the past 12 months. Choose the answer that is mostly right for you.

These questions are asking about risky drug use, including:

  • Using more of a drug than your doctor prescribes or more than the instructions say to use.
  • Using a drug even though you don't have a medical reason to use it.
  • Using illegal drugs.

Drugs may include:

  • Cannabis (marijuana, hashish).
  • Solvents, such as paint thinner.
  • Tranquilizers, such as Valium.
  • Barbiturates.
  • Cocaine.
  • Stimulants, such as speed (meth).
  • Hallucinogens, such as LSD.
  • Opioids, such as hydrocodone, oxycodone, or heroin.

If you think you might have a drug problem, see a doctor no matter what your results are from this quiz.

The results you get depend on how honest you are when you answer the questions.

Read and answer every question. If you feel a question is hard to answer, choose the answer that you feel is mostly right.


In the past 12 months:


Yes


No

1. Have you used drugs other than the ones you needed for medical reasons?



2. Have you used more than one drug at a time without a medical reason or without your doctor telling you to?



3. Is it hard for you to stop using drugs when you want to?



4. Have you ever had a blackout or flashback from using drugs?



5. Have you ever felt bad or guilty about using drugs?



6. Have your friends or family ever complained about your drug use?



7. Have you neglected your family because of your drug use?



8. Have you done anything illegal so you can get drugs?



9. Have you felt sick (had withdrawal symptoms) when you stopped using drugs?



10. Have you had health problems because of your drug use? (For example, have you had memory loss, hepatitis, convulsions, or bleeding?)




Total



Your score indicates the degree of problems that your drug use may cause:

  • 0 = No problems related to drug use. You probably do not have a problem with drug misuse or addiction.
  • 1 to 2 = Low risk of a drug problem. Your drug use may not be causing serious problems at this time. But you should talk to your doctor about your drug use.
  • 3 to 5 = Medium risk of a drug problem. You likely have a problem with drug misuse or addiction. Make an appointment with your doctor to discuss your drug use.
  • 6 to 8 = Serious risk of a drug problem. You likely have a serious problem with drug misuse or addiction. Call your doctor now to make an appointment.
  • 9 to 10 = Severe risk of a drug problem. You are almost certainly addicted to drugs. Call your doctor now to make an appointment.

Adapted from "Drug Use Questionnaire," © Copyright 1982 by Harvey A. Skinner, PhD, and the Centre for Addiction and Mental Health, Toronto, Canada.

Credits

Current as of: November 15, 2023

Author: Ignite Healthwise, LLC Staff
Clinical Review Board
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

Current as of: November 15, 2023

Author: Ignite Healthwise, LLC Staff

Clinical Review Board
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

Dear patient

I am excited to announce that I will be relocating my practice to Houston Methodist DeBakey Cardiology Associates. Starting November 4, 2024, my new address will be:

Houston Methodist DeBakey Cardiology Associates
6550 Fannin St.
Smith Tower, Suite 1901
Houston, TX 77030

Please note that my phone number and fax number will also change to the following:
24-Hour Telephone: 713-441-1100
Fax: 713-790-2643
Clinical Support Telephone (M-F, 8-5): 713-441-3515

I am excited about caring for you in my new office and hope you will make the transition with me. I will also continue to refill your medications as I have in the past. To assist, please provide your pharmacy with my new contact information.

Please consider checking your prescription refills to verify that you have enough medication on hand to last you until your next visit. Please note that your medical records will remain at my former office until you authorize their transfer. If you choose for me to continue providing your medical care, please complete and sign the enclosed “Authorization for Release of Medical Records” form and fax it to 713-790-2643. Once we receive your authorization, we will be happy to process the request for you.

Thank you for entrusting me with your medical care. My new team and I are dedicated to making this transition as seamless as possible. For help scheduling an appointment and transitioning your care, please call my new office number above.

I look forward to continuing your care at my new location.

Sincerely,
Gopi A. Shah, MD

Dear patient

Dr. Albert Raizner, Dr. Michael Raizner, and Dr. Mohamed El-Beheary are excited to announce that our practice, Houston Cardiovascular Associates, will merge with Houston Cardiovascular Associates on November 1, 2024.

Our new offices are similarly located in Houston, near the Texas Medical Center and in Sugar Land. Our in-hospital care will continue at Houston Methodist Hospital in the Texas Medical Center and Houston Methodist Sugar Land Hospital. Importantly, our new offices expand our services with state-of-the-art equipment and amenities. Our core values will always be, as they began over 40 years ago when Dr. Albert Raizner founded HCA:

Integrity – Compassion – Accountability

Our new address and contact information are:

Your medical records are confidential and remain available at our new locations. We consider it a privilege to serve as your cardiologists and look forward to your continuing with us. However, should you desire to transfer to another physician, you may request a copy of your records by contacting us at our new addresses and phone numbers listed above.

We thank you for your trust and loyalty. As always, we will continue to be here to take care of you. Please do not hesitate to contact us if you have any questions or concerns.

Sincerely,

Dr. Albert Raizner,
Dr. Michael Raizner,
Dr. Mohamed El-Beheary