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DOEP Drug Screen
Brian Knaack
2022-08-15T19:34:13-05:00
DOEP Drug Screen
"
*
" indicates required fields
Consider only
the last 12 months
when answering these questions.
Name
*
First
Middle Initial
Last
Email
*
1. Did you use larger amounts of drugs or use them for a longer time than you planned or intended?
*
Yes
No
2. Did you try to cut down on your drug use but were unable to do it?
*
Yes
No
3. Did you spend a lot of time getting drugs, using them, or recovering from their use?
*
Yes
No
4. Did you get so high or sick from drugs that it kept you from doing work, going to school, or caring for children?
*
Yes
No
5. Did you get so high or sick from drugs that it caused an accident or put you or others in danger?
*
Yes
No
6. Did you spend less time at work, school, or with friends so that you could use drugs?
*
Yes
No
7. Did your drug use cause emotional or psychological problems?
*
Yes
No
8. Did your drug use cause problems with family, friends, work, or police?
*
Yes
No
9. Did your drug use cause physical health or medical problems?
*
Yes
No
10. Did you increase the amount of a drug you were taking so that you could get the same effects as before?
*
Yes
No
11. Did you ever keep taking a drug to avoid withdrawal symptoms or keep from getting sick?
*
Yes
No
12. Did you get sick or have withdrawal symptoms when you quit or missed taking a drug?
*
Yes
No
Hidden
Do not use 13. Which drug caused the most serious problem?
*
None
Alcohol
Marijuana/Hashish
Hallucinogens/LSD/PCP/Psychedelics/Mushrooms
Inhalants
Crack/Freebase
Heroin and Cocaine (mixed together as Speedball)
Cocaine (by itself)
Heroin (by itself)
Street Methadone (non-prescription)
Other Opiates/Opium/Morphine/Demerol
Methamphetamine
Amphetamines (other uppers)
Tranquilizers/Barbiturates/Sedatives (downers)
13. Which drug caused the most serious problem?
*
None
Alcohol
Marijuana/Hashish
Hallucinogens/LSD/PCP/Psychedelics/Mushrooms
Inhalents
Crack/Freebase
Heroin and Cocaine (mixed together as Speedball)
Cocaine (by itself)
Heroin (by itself)
Street Methadone (non-prescription)
Other Opiates/Opium/Morphine/Demerol
Methamphetamine
Amphetamines (other uppers)
Tranquilizers/Barbituates/Sedatives (downers)
Hidden
Course Date
MM slash DD slash YYYY
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