1. I have lost interest in or given up activities previously important to me.
(Examples: sports, extracurricular activities, hobbies) | YES NO |
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| 2. I have missed school, skipped classes, not been doing my assignments regularly, and/or my grades have dropped. | YES NO |
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| 3. I have found myself doing things against my values that I would not have done previously, such as lying, stealing or sexual acting out. | YES NO |
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| 4. I have been more defiant and hostile to authority figures. | YES NO |
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| 5. My relationship with my parents and other family members is not as good. | YES NO |
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| 6. I have isolated myself from my family and not participated in family outings. | YES NO |
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| 7. I have found it hard to socialize with my friends without using and often use drugs and/or alcohol to feel comfortable. | YES NO |
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| 8. I notice I am using to cope with or escape my problems. | YES NO |
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| 9. I have engaged in risky behaviors, such as going into dangerous neighborhoods, being involved in gang related activities, having unprotected sex, using drugs and chemicals without knowing what might be in them, or illegal behaviors like driving under the influence, using cigarettes or alcohol under age, or selling drugs. | YES NO |
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| 10. My moods change more than in the past; for example, I may vary from sad, angry, irritable and easily frustrated. | YES NO |
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| 11. I find myself thinking about or craving drugs and/or alcohol, or I can't wait for the weekend or the next party or other opportunity to use. | YES NO |
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| 12. I have experienced 'blackouts' (present inability to remember behavior when I was using, although I was fully conscious and appeared normal at the time.) | YES NO |
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| 13. I get angry, irritable, edgy or agitated if I can't use a drug or alcohol when I want to. | YES NO |
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| 14. I feel restless, irritable, easily distracted after the effects of the drug have worn off. | YES NO |
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| 15. I can't remember the last time I was really happy. | YES NO |
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