Drug Screening Form
After filling the details click on the SUBMIT button.
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indicates required fields
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Have you used non prescribed drugs?:
Yes
No
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Have you abused prescription drugs?:
Yes
No
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Do you abuse more than one drug at a time?:
Yes
No
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Do you use drugs more than once a week?:
Yes
No
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Have you tried stop using drugs and were unable?:
Yes
No
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Have you had blackouts or flashbacks due to drugs?:
Yes
No
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Do you ever feel bad/guilty about your drug use?:
Yes
No
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Has your family ever complain about your drug use?:
Yes
No
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Has drugs ever created problems with your family?:
Yes
No
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Have you lost friends due to your use of drugs?:
Yes
No
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Have you neglected family due your use of drugs?:
Yes
No
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Been in trouble at work due to your use of drugs?:
Yes
No
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Have you lost a job because of drug abuse?:
Yes
No
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Gotten into fights due to the use of drugs?:
Yes
No
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Engaged illegal activities to obtain drug?:
Yes
No
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Been arrested for possession of illegal drugs?:
Yes
No
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Ever felt sick when you stopped using drugs?:
Yes
No
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Had medical problems from using drugs?:
Yes
No
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Asked anyone for help for a drug problem?:
Yes
No
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Been involved in a treatment program for drugs?:
Yes
No
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How many "Yes" answers did you select?:
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How many "No" answers did you select?:
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Name:
*
E-mail:
Address:
Phone:
*
Please contact me by::
E-mail
Phone
Postal Mail
Any of the above
Do not contact me - Pray
After filling the details click on the SUBMIT button.
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After filling the details click on the SUBMIT button.
