Sub Abuse Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *D.O.BMarital status:EthnicityCaucasianHispanicNative AmericanAfrican-AmericanOtherDo you know how much your family or loved ones worry about your alcohol or drugs? Do they get angry if someone try to discuss your drinking or drug use? Do you lie or make excuses about your behavior when you drink or use drugs? Have you ever been hurt or embarrassed by your behavior when you are drunk or under the influence? Do you have concerns about how much time and money you spend on alcohol and drugs? Do your resent having to pick up your responsibilities because you are drunk, high or havehangovers?Did you ever got scared or became nervous when you are drinking or using drugs? Have somebody ever considered calling the police because of your alcohol or drug use or for your behavior while under the influence? 1. Have you used drugs other than those required for medicinal reasons? YesNo2. Have you abused prescription drugs? YesNo3. Do you abuse more than one drug at a time? YesNo4. Can you get through the week without using drugs? YesNo5. Are you always able to stop using drugs when you want to? YesNo6. Have you had "blackouts" or "flashbacks" as a result of drug use? YesNo7. Do you ever feel bad or guilty about your drug use? YesNo8. Does your spouse (or parents) ever complain about your involvement with drugs? YesNo9. Has drug abuse created problems between you and your spouse or your parents? YesNo10. Have you lost friends because of your use of drugs? YesNo11. Have you neglected your family because of your use of drugs? YesNo12. Have you been in trouble at work because of drug abuse? YesNo13. Have you lost a job because of drug abuse? YesNo14. Have you gotten into fights when under the influence of drugs? YesNo15. Have you engaged in illegal activities in order to obtain drugs? YesNo16. Have you been arrested for possession of illegal drugs? YesNo17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? YesNo18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)? YesNo19. Have you gone to anyone for help for a drug problem? YesNo20. Have you been involved in a treatment program specifically related to drug use? YesNoList all the substances your have ever used in past, how often and how long did you use?WebsiteSubmit