Screening for Drug Use in General Medical Settings*

Instructions: For each substance, mark in the appropriate column. For example, if the patient has used Cocaine in their lifetime, put a mark in the "Yes" column in the "cocaine" row.

For more detailed instructions on implementing drug use screening, please see NIDA's Screening Resource Guide.

Pre-Screening Question

In your life, which of the following substances have you ever used?

Please report nonmedical use only:
Do not record medications that are used as prescribed by your doctor.

	Yes	No
Tobacco products (cigarettes, chewing tobacco, cigars, etc.)	Yes	No
Alcoholic beverages (beer, wine, liquor, etc.)	Yes	No
Cannabis (marijuana, pot, grass, hash, etc.)	Yes	No
Cocaine (coke, crack, etc.)	Yes	No
Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, diet pills, etc.)	Yes	No
Methamphetamine (speed, crystal, ice, etc.)	Yes	No
Inhalants (nitrous oxide, glue, gas, paint thinner, etc.)	Yes	No
Sedatives or sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc.)	Yes	No
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, Ecstasy, etc.)	Yes	No
Street opioids (heroin, opium, etc.)	Yes	No
Prescription opioids (fentanyl, oxycodone [OxyContin, Percocet], hydrocodone [Vicodin], methadone, buprenorphine, etc.)	Yes	No
Other:	Yes	No

        

Note: This website collects no personally identifiable information and does not store your responses to any of the following questions.

*This screening tool was adapted from the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) Version 3.0, developed and published by the WHO.