Assessment Tool

STEP 1: Tell us about your drug use
What drugs are you currently taking?

Hydrocodone (Vicodin, Hycodan)Morphine (MS Contin, Kadian)HeroinOxycodone (Oxycontin, Percoset)Hydromorphone (Dilaudid)Fentanyl (Duragesic)Suboxone (Buprenorphine)Methadone (Dolophine)Benzodiazepines (Xanax, Valium, Klonopin)Other

Has a doctor prescribed the drug for you?

Yes, I have a current prescriptionYes, but I’m also taking drugs for which I don’t have a prescriptionNo, but a doctor prescribed a drug in the pastNo, I’ve never had a prescription for the drugs

What drug were you originally prescribed?

Hydrocodone (Vicodin, Hycodan)Morphine (MS Contin, Kadian)Oxycodone (Oxycontin, Percoset)Hydromorphone (Dilaudid)Fentanyl (Duragesic)Suboxone (Buprenorphine)Methadone (Dolophine)Benzodiazepines (Xanax, Valium, Klonopin)Other

How long have you been using the drug?

1 Month or less1 - 6 Months7 - 12 Months1 - 2 YearsMore than 2 years

STEP 2: What treatments have you tried?
Have you tried to stop taking drugs?

Yes, with the help of a professionalYes, with the help of friends and familyYes, on my ownNo

How have you tried to quit?

Cold turkeyGradual weaningWith chemical detox (Naloxone, Naltrexone)Inpatient DetoxOutpatient ProgramGroup or Individual Therapy

How many times have you attempted to quit?

01234

How long ago did you try to quit?

1 Month or less1 - 6 Months7 - 12 Months1 - 2 YearsMore than 2 years

STEP 3: Tell us about your symptoms
Are you experiencing pain associated with your original prescription?

NoYes, I have chronic painYes, I have preexisting pain associated with my prescriptionYes, I have pain and it has gotten worseYes, I have pain and it has decreased

Please select any associations you have with your drug use

AnxietyDepressionPanicPainDiscomfortAddiction

STEP 4: Get your results
First Name

Last Name

Email

Phone Number

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