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| Mark each box that applies | YES | No |
|---|---|---|
| Family history of substance abuse | ||
| Alcohol | 1 | 0 |
| Illegal drugs | 1 | 0 |
| Prescription drugs | 1 | 0 |
| Personal history of substance abuse | ||
| Alcohol | 1 | 0 |
| Illegal drugs | 1 | 0 |
| Prescription drugs | 1 | 0 |
| Age between 16 and 45 years | 1 | 0 |
| Psychological disease | ||
| ADD, OCD, bipolar, schizophrenia | 1 | 0 |
| Depression | 1 | 0 |
| Scoring totals |
ADD, attention deficit disorder; OCD, obsessive compulsive disorder.
Table reprinted with permission from ref.69, Elsevier.
