DRUG USE QUESTIONNAIRE (DAST – 10)



The following are some questions given to patients who are on or being considered for medication for their pain. Please answer each question as honestly as possible. There are no right or wrong answers. Name:___________________________________________DOB:__________________NeverSeldomSometimesOftenVery Often012341. How often do you have mood swings?2. How often have you felt a need for higher doses of medication to treat your pain?3. How often have you felt impatient with your doctors?4. How often have you felt that things are just too overwhelming that you can’t handle them?5. How often is there tension in the home?6. How often have you counted pain pills to see how many are remaining?7. How often have you been concerned that people will judge you for taking pain medication?8. How often do you feel bored?9. How often have you taken more pain medication than you were supposed to?10. How often have you worried about being left alone?11. How often have you felt a craving for medication?12. How often have others expressed concern over your use of medication?13. How often have any of your close friends had a problem with alcohol or drugs?14. How often have others told you that you had a bad temper?15. How often have you felt consumed by the need to get pain medication?16. How often have you run out of pain medication early?17. How often have others kept you from getting what you deserve?18. How often, in your lifetime, have you had legal problems or been arrested?19. How often have you attended an AA or NA meeting?20. How often have you been in an argument that was so out of control that someone got hurt?21. How often have you been sexually abused?22. How often have others suggested that you have a drug or alcohol problem?23. How often have you had to borrow pain medications from your family or friends?24. How often have you been treated for an alcohol or drug problem? Physician/Provider Signature:__________________________ Date:_________Stenosis Questionnaire:Do you have pain or weakness in your legs and/ or back when standing and walking?LegsBackBothDoes the pain or weakness in your legs get worse the longer you stand or walk?YesNoI do not have pain or weakness in my legsHow would you describe the pain or weakness in your legs (mark all that apply)NumbnessAchingCrampingShootingFatigue/WeaknessI do not have pain or weakness in my legsIs the pain or weakness in your legs while walking relieved when you lean over objects such as a walker or shopping cart?YesNoI do not have pain or weakness in my legsDoes the pain or weakness in your back get worse the longer you stand or walk?YesNoI do not have pain or weakness in my backHow would you describe the pain or weakness in your back (mark all that apply)NumbnessAchingCrampingShootingFatigue/ WeaknessI do not have pain or weakness in my backIs the pain or weakness in your back while walking relieved when you lean over objects such as a walker or shopping cart?YesNoI do not have pain or weakness in my backIs the pain or weakness in your legs relieved when you sit down?YesNo I do not have pain or weakness in my legsIs the pain or weakness in your back relieved when you sit down?Yes No I do not have pain or weakness in my backVF-LD-0056-8-F ?2017 Vertiflex, Inc. All Rights ReservedSF-12?Page 1 of 2Date _______________________________________________________________________________Patient Name ________________________________________________________________________Date of Birth _________________________________________________________________________SF-12?: This information will help your doctors keep track of how you feel and how well you are able to do your usual activities. Answer every question by placing a check mark on the line in front of the appropriate answer. It is not specific for arthritis. If you are unsure about how to answer a question, please give the best answer you can and make a written comment beside your answer.1. In general, would you say your health is: ____ Excellent (1) ____ Very Good (2) ____ Good (3) ____ Fair (4) ____ Poor (5) The following two questions are about activities you might do during a typical day. Does YOUR HEALTH NOW LIMIT YOU in these activities? If so, how much? 2. MODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf: ____ Yes, Limited A Lot (1) ____ Yes, Limited A Little (2) ____ No, Not Limited At All (3)3. Climbing SEVERAL flights of stairs: ____ Yes, Limited A Lot (1) ____ Yes, Limited A Little (2) ____ No, Not Limited At All (3)During the PAST 4 WEEKS, have you had any of the following problems with your work or other regular activities AS A RESULT OF YOUR PHYSICAL HEALTH?4. ACCOMPLISHED LESS than you would like: ____ Yes (1) ____ No (2)5. Were limited in the KIND of work or other activities? ____ Yes (1) ____ No (2)During the PAST 4 WEEKS, were you limited in the kind of work you do or other regular activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)?6. ACCOMPLISHED LESS than you would like: ____ Yes (1) ____ No (2)7. Didn’t do work or other activities as CAREFULLY as usual: ____ Yes (1) ____ No (2)Provider Initials _______ Date __________SF-12?Page 2 of 2Date _______________________________________________________________________________Patient Name ________________________________________________________________________Date of Birth _________________________________________________________________________SF-12? Cont’d:8. During the PAST 4 WEEKS, how much did PAIN interfere with your normal work (including both work outside the home and housework)? ____ Not At All (1) ____ A Little Bit (2) ____ Moderately (3) ____ Quite A Bit (4) ____ Extremely (5)The next three questions are about how you feel and how things have been DURING THE PAST 4 WEEKS. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the PAST 4 WEEKS –9. Have you felt calm and peaceful? ____ All of the Time (1) ____ Most of the Time (2) ____ A Good Bit of the Time (3) ____ Some of the Time (4) ____ A Little of the Time (5) ____ None of the Time (6)10. Did you have a lot of energy? ____ All of the Time (1) ____ Most of the Time (2) ____ A Good Bit of the Time (3) ____ Some of the Time (4) ____ A Little of the Time (5) ____ None of the Time (6)11. Have you felt downhearted and blue? ____ All of the Time (1) ____ Most of the Time (2) ____ A Good Bit of the Time (3) ____ Some of the Time (4) ____ A Little of the Time (5) ____ None of the Time (6)12. During the PAST 4 WEEKS, how much of the time has your PHSYCIAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities (like visiting with friends, relative, etc.)? ____ All of the Time (1) ____ Most of the Time (2) ____ A Good Bit of the Time (3) ____ Some of the Time (4) ____ A Little of the Time (5) ____ None of the Time (6)Provider Signature: __________________________________ Date: __________SF-12? Health Survey ?1994, 2002 by Medical Outcomes Trust and QualityMetric Incorporated. All Rights ReservedSF-12? is a registered trademark of Medical Outcomes TrustNAME:Date: DRUG USE QUESTIONNAIRE (DAST – 10)The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months. Carefully read each statement and decide if your answer is “Yes” or “No”. Then, circle the appropriate response beside the question.In the statements “drug abuse” refers to (1) the use of prescribed or over-the-counter drugs may include: cannabis (e.g. marijuana, hash), solvents, tranquillizers (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.These questions refer to the past 12 monthsCircle Your ResponseHave you used drugs other than those required for medical reasons?YesNoDo you abuse more than one drug at a time?YesNoAre you always able to stop using drugs when you want to?YesNoHave you had “blackouts” or “flashbacks” as a result of drug use?YesNoDo you ever feel bad or guilty about your drug use?YesNoDoes your spouse (or parents) ever complain about yourYesNo Involvement with drugs?Have you neglected your family because of your use of drugs?YesNoHave you engaged in illegal activities in order to obtain drugs?YesNoHave you ever experienced withdrawal symptoms (felt sick) whenYesNo you stopped taking drugs?Have you had medical problems as a result of your drug useYesNo (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?BDI-IIBeck Depression InventorySadness0 I do not feel sad.1 I feel sad much of the time.2 I am sad all the time.3 I am so sad or unhappy that I can’t stand it.Pessimism0 I am not discouraged about my future.1 I feel more discouraged about my future than it used to be2 I do not expect things to work out for me.3 I feel my future is hopeless and will only get worse.Past failure0 I do not feel like a failure1 I have failed more than I should have.2 As I look back, I see a lot of failures3 I feel I am a total failure as a personLoss of Pleasure0 I get as much pleasure as I ever did from the things I enjoy.1 I don’t enjoy things as much as I used to.2 I get very little pleasure from the things I used to enjoy.3 I can’t get any pleasure from the things I used to enjoy. Guilty Feelings0 I don't feel particularly guilty.1 I feel guilty over many things I have done or should have done.2 I feel quite guilty most of the time.3 I feel guilty all of the time. Punishment Feelings0 I don't feel I am being punished.1 I feel I may be punished.2 I expect to be punished.3 I feel I am being punished.Self-dislike0 I feel the same about myself as ever.1 I have lost confidence in myself.2 I am disappointed in myself.3 I dislike myself.Self-Criticalness0 I don't criticize or blame myself more than usual. 1 l am more critical of myself than I used to be.2 I criticize myself for all my faults.3 I blame myself for everything bad that happensSuicidal Thoughts or Wishes0 l don't have any thoughts of killing myself.1 I have thoughts of killing myself, but I would not carry them out.2 I would like to kill myself.3 I would kill myself if I had the chance.10.Crying0 I don't cry any more than I used to.1 I cry more than I used to.2 I cry over every little thing.3 I feel like crying, but I can't.Name:___________________________________ DOB____________Instructions: This questionnaire consists of 21 groups of statements. Please read each group of statements carefully1 and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today; Circle the number beside the statement you have picked. If several statements in the group seem to apply equally well, circle the highest number for that group. Be sure that you do not choose more than one statement for any group, including Item 16 (Changes in Sleeping Pattern) or Item 18{Changes ln Appetite).Agitation0 I am no more restless or wound up than usual. 1 I feel more restless or wound up than usual.2 I am so restless or agitated that it's hard to stay still.3 I am so restless or agitated that I must keep moving or doing something.Loss of interest0 I have not last interest in other people or activities.1 I am less interested in other people or things than before.2 I have lost most of my interest in other people or things.3 It's hard to get interested in anything.Indecisiveness0 I make decisions about as well as ever.1 I find it more difficult to make decisions than usual.2 I have much greater difficulty in making decisions than I used to.3 I have trouble making any decisions.Worthlessness0 I do act feel I am worthless.1 I don't consider myself as worthwhile and useful as I used to.2 I feel more worthless as compared to other people.3 I feel utterly worthless.Loss of Energy0 I have as much energy as ever.1 I have less energy than I used to have.2 I don't have enough energy to do very much.3 I don't have enough energy to do anything.Changes in Sleeping Pattern0 I have not experienced any change in my sleeping pattern.1a I sleep somewhat more than as usual. 1b I sleep somewhat less than usual. 2a I sleep a lot more than usual.2b I sleep a lot less than usual. 3a I sleep most of the day.3b I wake op 1-2 hour early and can't get back to sleep.Irritability0 I am no more irritable than usual.1 I am more irritable than usual2 I am much more Irritable than usual.3 I am irritable all the time.Changes in Appetite0 I have not experienced any change in my appetite.1a My appetite is somewhat less than usual.lb My appetite is somewhat greater than usual.2a My appetite is much less than before.2b My appetite is much greater than usual.3a I have no appetite at all3b I crave food all the time.Concentration Difficulty0 I can concentrate as well as ever.1 I can't concentrate as wen as usual.2 It's hard to keep my mind on anything for very long.3 I find I can't concentrate on anythingTiredness or Fatigue0 I am no more tired or fatigued than usual.1 I get more tired or fatigued more easily than usual.2 I am too tired or fatigued to do a lot of the things I used to do.3 I am too tired or fatigued to do most of the things I used to do.Loss of Interest in Sex0 I have not noticed any recent change in my interest in sex.1 I am less interested in sex than I used to be.2 I am much less interested in sex now.3 I have lost interest in sex completely. ................
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