Drug Screening Questionnaire
Information: This questionnaire is part of your evaluation and an opportunity to identify any concern related to drug use (whether they were prescribed or not), even if you are sure that your habits do not point in this direction.
The questionnaire may use any of the following words:
OTC (over-the-counter): these are medications for which you do not need a prescription to buy, such as Aspirin;
Drug abuse: the use of any drug in excess of the directions given, or used for non-medical use (ex. recreational);
Blackout: a state of cognitive impairment, associated to a sense of loss of time and memory impairment
Flashback: a sudden, at times disturbing (vivid) memory of an event in the past
Direction: Consider the past year (12 to 14 months) and after you have read carefully each question/statement answer YES or NO. If you are unsure about any question or if a statement appears difficult choose the answer that best fit your experience.