S2A  QUESTIONNAIRE

Patient Identifier:__________________________________________________________

Age__________________________

Gender_______________________

Ethnicity______________________

Diagnoses: ______________________________________________________________

Patient Self-Administered     YES         NO

Administered by:________________________________
 

Have you ever had a drink containing alcohol (including beer, wine, wine coolers)?     YES         NO

If yes, list which ones: _________________________________________________________________________________

What illicit drugs have you used? (List them in order, starting with the drug you used most)

1. ____________________ 3. ____________________ 5. ____________________ 7. ____________________

2. ____________________ 4. ____________________ 6. ____________________ 8. ____________________
 
 

What prescribed drugs have you used?

1. ____________________ 2. ____________________ 3. ____________________ 4. ____________________

When in your life did you do the most drinking and drug using? __________________________________________________
 

The following questions inquire about things that were happening during two different time periods. First, we would like you to tell us about what was going on in the past year, or if you are in a hospital or in jail, what was happening in the year before you were put there. Then we would like you to tell us about what was going on during the time that you did the most drinking and drugging.

This first set of questions asks about how often you were drinking or using other drugs, and also how often certain things happened to you. Please answer each question twice, once for how often things were happening in the past year, and once for how often things were happening when you were drinking and using drugs the most. Fill in both of the boxes next to each question with the letter corresponding to the answer that comes closest to matching how often these things were happening:
 
a
b
c
d
e
Never
Monthly or less
2-4 times per month
2-3 times per week
More than 3 times per week

 
When you were drinking/ using the most?
In the past year?

 
 

a = never

b = monthly 

c = 2-4 times per month

d = 2-3 times per week

e = more than 3 times per week

Q01 How often did you drink alcohol (including beer, wine, wine coolers)?    
Q03 When you are not in the hospital or in jail, how often did you use drugs other than alcohol?    
Q04 How often did you use more than one drug at a time?    
Q05 How often did you have 6 or more drinks on one occasion?    
Q06 How often did you use more of your prescribed drugs than your doctor ordered, or use your prescribed drugs for purposes other than what your doctor intended?    
Q07 How often did you sniff, huff, or inhale anything like paint, glue, gasoline, freon, or some other substance?    
Q02 On those days you drank, about how many drinks do you have?
1 - 2
3 - 4
5 - 6
7 - 9
10 or more

The next set of questions also asks about how often you were drinking or using other drugs, and also how often certain things happened to you. Please remember to answer each question twice, once for how often things were happening in the past year, and once for how often things were happening when you were drinking and using drugs the most. Fill in both of the boxes next to each question with the letter corresponding to the answer that comes closest to matching how often these things were happening:
 
 
a
b
c
d
e
Never
Less often than monthly
Monthly
Weekly
Daily or almost daily
   
When you were drinking/ using the most?
In the past year?
 
C01 How often have you been unable to remember what happened the night before because you had been drinking    
 
 
 
 
 
 
 
 
 
 
 
 

a = never

b = less often than monthly

c = monthly

d = weekly

e = daily or almost daily

C02 How often have you been unable to remember what happened the night before because you had been using other drugs?    
C03 How often during the last year have you found that you were not able to stop drinking once you had started?    
C04 How often during the last year have you had a feeling of guilt or remorse after drinking?    
C05 How often during the last year have you had a feeling of guilt or remorse after using other drugs?    
C06 How often have you attended Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or another self-help group to help you with your alcohol or other drug use?    
C07 How often did you need a first drink in the morning to get yourself going after a heavy drinking session?    
C08 How often did you need some other drug(s) in the morning to get yourself going again?    
F01 How often has someone close to you complained about your drinking (your spouse, boyfriend/girlfriend, a relative, a healthcare worker)?    
F02 How often has someone close to you complained about your other drug use (your spouse, boyfriend/girlfriend, a relative, a healthcare worker)?    
W01 How often have you had problems at work because of drinking?    
W02 How often have you had problems at work because of other drug use?    
M01 How often have you had severe shaking, heard voices, or seen things that werenít there after heavy drinking?    
M02 How often have you felt sick after you stopped taking drugs?    
L01 How often have you gotten into fights when drinking?    
L02 How often have you gotten into fights when using other drugs?    
L03 How often have you or someone else been injured as a result of your drinking?    
L04 How often have you or someone else been injured as a result of your other drug use?    
L05 How often have you engaged in illegal activities to obtain drugs?    

 

For the next set of questions, please put a check in the box that most closely matches what was happening WHEN YOU WERE DRINKING OR USING THE MOST:
 
  WHEN YOU WERE DRINKING OR USING OTHER DRUGS THE MOST
More than most others
About the same as others
Less than others
Q08h Compared to other people, do you think you were drinking:      
Q09h Compared to other people, do you think you were using other drugs:      
Q10h Compared to other people, do your friends or relatives think you were drinking      
Q11h Compared to other people, do your friends or relatives think you were using other drugs      

Put a check in the box that most closely matches what has happened IN THE PAST YEAR:
 
  WHEN YOU WERE DRINKING OR USING OTHER DRUGS THE MOST
More than most others
About the same as others
Less than others
Q08y Compared to other people, do you think you were drinking:      
Q09y Compared to other people, do you think you were using:      
Q10y Compared to other people, do your friends or relatives think you were drinking      
Q11y Compared to other people, do your friends or relatives think you were using      

 

Do you ever try to limit your drinking to certain times of the day or to certain places?
 
 

What happened that caused you to do that?
 
 

Please check the appropriate box:
 
   
NO
YES
YES, but not in the past year
T01 Can you get through the week without using drugs?      
T02 Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?      
T03 Have you had "blackouts" or "flashbacks" as a result of drug use?      
T04 Are you always able to stop drinking when you want to?      
T4a Do you use more than one drug at a time?      
T05 Are you always able to stop using drugs when you want to?      
T06 Do you ever feel bad or guilty about your drinking?      
T07 Do you ever feel bad or guilty about your drug use?      
T08 Do you ever try to limit your drinking to certain times of the day or to certain places?      
T09 Have you ever attended a meeting of Alcoholics Anonymous (AA)?      
T10 Can you stop drinking without a struggle after one or two drinks?      
T11 Does anyone close to you (wife/husband, girlfriend/boyfriend, parents, family member, or close friend) ever worry or complain about your drinking?      
T12 Does your spouse (or parents) ever complain about your involvement with drugs?      
T13 Has drinking ever created problems in your love relationship?      
T14 Has your drug abuse created problems between you and your spouse or your parents?      
T15 Has anyone close to you ever gone for help about your drinking?      
T16 Have you ever lost friends or girlfriends/boyfriends because of drinking?      
T17 Have you lost friends because of use of drugs?      
T18 Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?      
T19 Have you neglected your family because of your use of drugs?      
T20 Have you ever neglected your obligations, your family or your work for two or more days in a row because you were drinking?      
T21 Have you ever gotten into trouble at work because of drinking?      
T22 Have you been in trouble at work because of your use of drugs?      
T23 Have you ever lost a job because of drinking?      
T24 Have you ever lost a job because of other drug use?      
T25 Do you ever drink before noon?       
T26 Have you ever been told you have liver trouble? Cirrhosis?      
T27 Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)       
T28 Have you ever had severe shaking, heard voices or seen things that weren't there after heavy drinking?      
T29 Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?      
T30 Have you ever gone to anyone for help about your drinking?      
T31 Have you gone to anyone for help for a drug problem?      
T32 Have you ever been in a hospital because of drinking?      
T33 Have you been involved in a treatment program especially related to drug abuse?      
T34 Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital where drinking was a part of the problem?      
T35 Have you ever been seen at a psychiatric or mental health clinic or gone to a doctor, social worker or clergyman for help with an emotional problem in which drinking has played a part?      
T36 Have you gotten into fights when drinking?      
T37 Have you gotten into fights when under the influence of drugs?      
T38 Have you engaged in illegal activities in order to obtain drugs?      
T39 Have you ever been arrested, even for a few hours, because of your behavior after you had been drinking?      
T40 Have you been arrested for possession of illegal drugs?      
T41 Have you ever been arrested for drunk driving after drinking?