CARD TOBACCO: Cigarettes, E- Cigarettes, Cigars, Tobacco Pipe, Chewing Tobacco, Snuff

Transcription

1 CARD 1 1. TOBACCO: Cigarettes, E- Cigarettes, Cigars, Tobacco Pipe, Chewing Tobacco, Snuff 2. ALCOHOL: Beer, Wine, Liquor 3. MARIJUANA: Grass, Pot, Hashish, Hash, Hash Oil, Weed, Ganja, Marijuana Edibles candy, drinks or other foods containing marijuana, vaporizer 4. COCAINE: Crack, Coke, Blow 5. AMPHETAMINES: Stimulants, Diet Pills, Ice, Khat, Methamphetamine, Ritalin, Adderall, Concerta, Cylert, Speed, Uppers, Crystal Meth, Crank 6. SEDATIVES: Barbiturates, Librium, Seconal, Sleeping Pills, Tranquilizers, Valium, Xanax, Downers, Quaaludes 7. INHALANTS: Glue, Toluene, Gasoline, Paint, Paint Thinner, Freon (DO NOT INCLUDE Nitrous Oxide, Amyl or Butyl Nitrite, or Ether) 8. HALLUCINOGENS: DMT, LSD or Acid, Mescaline, Mushrooms, Peyote, Psilocybin, Coricidin/Dextromethorphan (C-C-C, Robo, Red Devils, DXM, Dex), Salvia 9. OPIATES: Heroin, Codeine, Vicodin, Darvon, Demerol, Dilaudid, Methadone, Morphine, Opium, Percodan, Talwin, T s & Blues, Oxycontin/Oxycodone 10. PCP: Angel Dust, Peace 11. MDMA: Ecstasy, Molly, XTC, Clarity, Essence, Adam, X, Lover s Speed 12. KETAMINE: Special K, K, Vitamin K, Cat Valiums, Kit Kat 13. GHB: Grievous Bodily Harm, G, Liquid Ecstasy, Georgia Home Boy 14. ROHYPNOL: Roofies, Rophies, Roche, Forget-me Pill, R2 15. OTHER: Nitrous Oxide, Spice/Black Mamba/K12, Bath Salts, 2CB, or other drugs not listed above.

2 CARD 2 Typical Pattern of Use 0 = No Use 1 = Less Than Once a Month 2 = Once a Month 3 = 2 or More Times a Month 4 = Once a Week 5 = 2 or More Times a Week Lifetime Use 1 = 1-2 Times 2 = 3-5 Times 3 = 6-9 Times 4 = Times 5 = Times 6 = 40 or More Times 6 = Once a Day 7 = More Than Once a Day

3 CARD 3 Tobacco 1. A doctor or nurse advised you to 2. Your family or friends asked you to 3. It cost too much 4. You got tired of it 5. It s bad for you 6. It caused unpleasant side effects 7. It was too inconvenient to continue 8. Pregnancy Alcohol/Drugs 1. A doctor or nurse advised you to 2. Your family or friends asked you to 3. It cost too much 4. You got tired of it 5. Drinking/Using Drugs is bad for you 6. It caused unpleasant side effects 7. Pregnancy 8. Legal Problems

4 CARD 4 Medicines Stimulants Sedatives Opioids Amphetamines Diet Pills Ritalin Adderall Concerta Cylert Other Stimulant Barbituates Librium Seconal Sleeping Pills Tranquilizers Valium Xanax Other Sedative Codeine Vicodin Darvon Demerol Dilaudid Methadone Morphine Percodan Talwin Oxycodone Other Opioid Drugs Marijuana or Grass or Pot Hashish Opioids Opium T s & Blues Stimulants Ice Khat Methamphetamine Speed Uppers Other Stimulant PCP Club Drugs Ecstasy or MDMA GHB Ketamine Rohypnol Other Club Drug Hallucinogens DMT LSD or Acid Mescaline Mushrooms Peyote Psilocybin Other Hallucinogen Cocaine Crack Inhalants Glue Toluene Gasoline Paint Paint Thinner Heroin Other Drugs Amyl nitrite or Poppers Anabolic Steroids Nitrous oxide Or Anything else

5 CARD 5 1. Feeling depressed 2. Feeling anxious, restless, or irritable 3. Have trouble concentrating 4. Feeling tired, sleepy, or weak 5. Have trouble sleeping 6. Tremble or twitch 7. Sweat or have fever 8. Feeling nauseated or vomit 9. Have diarrhea or stomachache 10. Have a change in appetite 11. See, hear, or feel things that weren t there 12. Have runny eyes or nose 13. Have seizures 14. Have muscle pains 15. Yawn a lot 16. Have a fast heart beat 17. Have vivid, unpleasant dreams 18. Have a headache 19. Crave this drug

6 CARD 6 Physical 1. Unintended weight loss or gain 2. A seizure 3. A persistent cough 4. Eye problems 5. An injury or burn 6. Heart pounding 7. Sexual difficulties 8. An overdose 9. A sore throat or sinus problems 10. Trembling, twitching, or numbness 11. Headaches or dizziness 12. Stomach problems 13. Kidney problems Emotional/Psychological 1. Feeling depressed or empty 2. Being paranoid or suspicious 3. Feeling confused 4. Feeling anxious or tense 5. Being irritable or aggressive 6. Feeling keyed up or overactive 7. Seeing, hearing, smelling, or feeling things that weren t there 8. Laughing or crying for no reason 9. Being jumpy or easily startled 10. Feeling overconfident or fearless