3. When was the last time you smoked or used marijuana? _________________ 4. Have you ever injected any illegal substance? Yes No 5. Have you ever abused any prescription medications (i.e. taking other than as directed)? Yes No 6. Have you ever used prescribed medications? Yes No anyone else’s What medication was it? ______________________________ Whose medication was it? 7. Did this person know you were using their medication? Yes No 8. Have you used any other illegal substance of any type? Yes No What illegal substance(s) have you used? List all drugs you have ever used illegally. FIRST TIME LAST TIME MAXIMUM # OF TIMES IN DRUG HOW USED NEVER USED USED TIMES USED PAST 5 YEARS Marijuana Hashish Heroin Cocaine
3. When was the last time you smoked or used marijuana? _________________ 4. Have you ever injected any illegal substance? Yes No 5. Have you ever abused any prescription medications (i.e. taking other than as directed)? Yes No 6. Have you ever used anyone else’s prescribed medications? What medication was it? ______________________________ Whose medication was it? Yes No 7. Did this person know you were using their medication? Yes No 8. Have you used any other illegal substance of any type? What illegal substance(s) have you used? Yes No List all drugs you have ever used illegally. DRUG FIRST TIME USED LAST TIME USED MAXIMUM TIMES USED # OF TIMES IN PAST 5 YEARS HOW USED NEVER Marijuana Hashish Heroin Cocaine
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