The Alcohol, Smoking and Substance Involvement Screening Test

In the past 3 months, how often have you used the following substances?

Some of the substances listed may be prescribed by a doctor (like amphetamines, sedatives, pain medications). We will not record medications that are used as prescribed by your doctor. However, if you have taken such medications for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please let us know.

1. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)

1 2 3 4 5

2. Alcoholic beverages (beer, wine, spirits, etc.)

1 2 3 4 5

3. Cannabis (marijuana, pot, grass, hash, etc.)

1 2 3 4 5

4. Cocaine (coke, crack, etc.)

1 2 3 4 5

5. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)

1 2 3 4 5

6. Inhalants (nitrous, glue, petrol, paint thinner, etc.)

1 2 3 4 5

7. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)

1 2 3 4 5

8. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)

1 2 3 4 5

9. Opioids (heroin, morphine, methadone, codeine, etc.)

1 2 3 4 5

10. Other, please specify:

1 2 3 4 5