Drug Screening Questionnaire (DAST)

Using drugs can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.

Patient name:

Date of birth:

methamphetamines (speed, crystal)

cannabis (marijuana, pot)

inhalants (paint thinner, aerosol, glue)

tranquilizers (valium)

cocaine

narcotics (heroin, oxycodone, etc.)

hallucinogens (LSD, mushrooms)

Others

How often have you used these drugs?

Monthly or less Weekly

Weekly

Daily or almost Daily

Yes

No

1. Have you used drugs other than those required for medical reasons?

2. Do you abuse more than one drug at a time?

3. Are you unable to stop using drugs when you want to?

4. Have you ever had blackouts or flashbacks as a result of drug use?

5. Do you ever feel bad or guilty about your drug use?

6. Does your spouse (or parents) ever complain about your involvement with drugs?

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

8. Have you engaged in illegal activities in order to obtain drugs?

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

Have you ever injected drugs?

Never

Yes, in the past 90 days

Yes, more than 90 days ago

Have you ever been in treatment for substance abuse?

Never

Currently

In the past

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