GAD-7 Questionnaire

ASSIST Screening Tool

Formulario en español
Patient Info

Question 1

In your life, which of the following substances have you ever used?

Substance Yes No
a. Cannabis (marijuana, pot, grass, hash, etc.)
b. Cocaine (coke, crack, etc.)
c. Prescription stimulants just for the feeling, more than prescribed, or that were not prescribed for you. (Ritalin, Adderall, diet pills, etc.)
d. Methamphetamine (meth, crystal, speed, ecstasy, molly, etc.)
e. Inhalants (nitrous, glue, paint thinner, poppers, whippets, etc.)
f. Sedatives just for the feeling, more than prescribed, or that were not prescribed for you. (sleeping pills, Valium, Xanax, tranquilizers, benzos, etc.)
g. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, ecstasy, etc.)
h. Street opioids (heroin, opium, etc.)
i. Prescription opioids just for the feeling, more than prescribed, or that were not prescribed for you. (Fentanyl, Oxycodone, OxyContin, Percocet, Vicodin, methadone, Buprenorphine, etc.)
j. Any other drugs to get high. Specify:

Question 2

In the past three months, how often have you used the substances you mentioned?

Substance Never Once or twice Monthly Weekly Daily or almost daily

Question 3

During the past three months, how often have you had a strong desire or urge to use the substances you mentioned?

Substance Never Once or twice Weekly Monthly Daily or almost daily

Question 4

During the past three months, how often has your use of the substances you mentioned led to health, social, legal, or financial problems?

Substance Never Once or twice Weekly Monthly Daily or almost daily

Question 5

During the past three months, how often have you failed to do what was normally expected of you because of your use of [FIRST DRUG, SECOND DRUG, ETC]?

Substance Never Once or twice Weekly Monthly Daily or almost daily

Question 6

Has a friend or relative or anyone else ever expressed concern about your use of the substances you mentioned?

Substance No, never Yes, in the past 3 months Yes, but not in the past 3 months

Question 7

Have you ever tried and failed to control, cut down, or stop using the substances you mentioned?

Substance No, never Yes, in the past 3 months Yes, but not in the past 3 months

Question 8

Have you ever used any drug by injection? (NON-MEDICAL USE ONLY)

Question 9

Extra drug injection questions

Once per week or less:
More than once per week:

Your total score for questions #2–7 for each substance

Total score for questions #2–7 for each substance

Score Indicated response
0–3 (0 – 4 for cannabis)
4 – 26 (5 – 26 for cannabis)
27+ (offer options that include treatment)

Brief education: Inform patients about the risks of illicit drug use and signs of a substance use disorder.

Brief intervention: Patient-centered discussion that employs Motivational Interviewing concepts to raise a patient’s awareness of their substance use and enhances their motivation to change their use. Brief interventions are typically performed in 3-15 minutes, and should occur in the same session as the initial screening. Repeated sessions are more effective than a one-time intervention.

If a patient is ready to accept treatment, a referral is a proactive process that facilitates access to specialized care for individuals likely experiencing a substance use disorder. These patients are referred to alcohol and drug treatment experts for more definitive, in-depth assessment and, if warranted, treatment. However, treatment also includes prescribing medications for substance use disorder as part of the patient’s normal primary care.