Patient Questionnaire (DAST)


DAST – 10

Name   

DOB  

These questions refer to the past 12 months.

Have you used drugs other than those required for medical reasons  

Do you abuse more than one drug at a time

Are you always able to stop using drugs when you want to? (If never used drugs, answer yes)

Have you had “blackouts” or “flashbacks” as a result of drug use?

Do you ever feel bad or guilty about your drug use? If never used drugs, choose No

Do your spouse (or parents) ever complain about your involvement with drugs?

Have you neglected your family because of your use of drugs?

Have you engaged in illegal activities in order to obtain drugs?

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding)?

 

Please add the total and select the appropriate DAST-10 Score 

 

Leave this empty:

Metamorphosis Pain Management https://www.metamorphosispain.com
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Document name: Patient Questionnaire (DAST)
Unique Document ID: 7dfc15a23b050bece80e10bebc9d1acaf0a7a46e
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2017-05-13 10:41:34 MSTPatient Questionnaire (DAST) Uploaded by Lisa Pearson - lisa@metamorphosispain.com IP 208.117.75.130