Page 1 of 2

Drug Screening (DAST-10)

Please let us know your name.
Invalid Input. Date of Birth.
Please let us know your email address just to send confirmation at the end of this form (optional).
Invalid Input. Date
The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months.
“Drug abuse” refers (1) the use of prescribed or over-the-counter drugs in excess of the directions, and (2) any nonmedical use of drugs.
The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages.
Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.
Invalid Input. Have you used drugs other than those required for medical reasons?
Invalid Input. Do you abuse more than one drug at a time?
Invalid Input. Are you unable to stop abusing drugs when you want to?
Invalid Input. Have you ever had blackouts or flashbacks as a result of drug use?
Invalid Input. Do you ever feel bad or guilty about your drug use?
Invalid Input. Does your spouse (or parents) ever complain about your involvement with drugs?
Invalid Input. Have you neglected your family because of your use of drugs?
Invalid Input. Have you engaged in illegal activities in order to obtain drugs?
Invalid Input. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
Invalid Input. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

Refresh Invalid Input. Please type what you see.