In the past 3 months	Yes	No
1. Did you smoke a cigarette containing tobacco?
1a. Did you usually smoke more than 10 cigarettes each day?
1b. Did you usually smoke within 30 minutes after waking?
Score for tobacco (count “yes” answers) Risk category: Low (0) Moderate (1 or 2) High (3)
2. Did you have a drink containing alcohol?
2a. On any occasion, did you drink more than 4 standard drinks of alcohol?
2b. Have you tried and failed to control, cut down or stop drinking?
2c. Has anyone expressed concern about your drinking?
Score for alcohol (count “yes” answers) Risk category: Low (0 or 1) Moderate (2) High (3 or 4)
3. Did you use cannabis?
3a. Have you had a strong desire or urge to use cannabis at least once a week or more often?
3b. Has anyone expressed concern about your use of cannabis?
Score for cannabis (count “yes” answers) Risk category: Low (0) Moderate (1 or 2) High (3)
4. Did you use an amphetamine‐type stimulant, or cocaine, or a stimulant medication not as prescribed?
4a. Did you use a stimulant at least once each week or more often?
4b. Has anyone expressed concern about your use of a stimulant?
Score for stimulants (count “yes” answers) Risk category: Low (0) Moderate (1 or 2) High (3)
5. Did you use a sedative or sleeping medication not as prescribed?
5a. Have you had a strong desire or urge to use a sedative or sleeping medication at least once a week or more often?
5b. Has anyone expressed concern about your use of a sedative or sleeping medication?
Score for sedatives (count “yes” answers) Risk category: Low (0) Moderate (1 or 2) High (3)
6. Did you use a street opioid (e.g., heroin) or an opioid‐containing medication not as prescribed?
6a. Have you tried and failed to control, cut down or stop using an opioid?
6b. Has anyone expressed concern about your use of an opioid?
Score for opioids (count “yes” answers) Risk category: Low (0) Moderate (1 or 2) High (3)
7. Did you use any other psychoactive substances? If yes, what did you take? (Not scored, but prompts further assessment)