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This questionnaire is used to assess college athletes who abuse drugs/alcohol/tobacco. This assessment may be used to help athletes identify what type of substance abuse they suffer from and act as a resource for the athlete to find further assistance in their return to sobriety. Substance abuse does not just include illegal drugs and alcohol, over the counter drugs, tobacco, and prescription medication has become a large aspect of substance abuse as of late. Refining the Problem
This questionnaire is directed to college athletes who are suspected by coaches, peers, athletic trainers and/or teammates to have a substance abuse problem. The questionnaire is to be used as instruments to raise awareness of substance abuse among athletes, and assist those who do suffer seek further help. Instrumentation/Methodology
This questionnaire will not only identify college athletes who do suffer from substance abuse, but also assist the administrator in recognizing what specific substances are being abused by the athlete. The athlete will be given a two part questionnaire to complete. The first aspect includes a list of commonly abused drugs and substances and the athlete is instructed to check off any that they have used ever, even just once. The second aspect of the questionnaire includes twelve yes or no questions directed toward the athletes past year substance usage. After the questionnaire is taken by the athlete and analyzed by the administrator the specific types of substance abuse will be addressed with the athlete. At that time if further help is needed the athlete will be provided with any type of counseling and services that the university offers Questionnaire
Please honestly circle any of the following substances that you have used even if only one
time.
1. Alcohol
2. Anabolic Steroids
3. Anesthetics
4. Antidepressants
9. Over the Counter
5. Cannabinoids
10. Sedatives
6. Hallucinogens
7. Inhailants
11. Stimulants
8. Opioids
All Circles around non-prescribed drugs = 1 point, prescribed medication= 0 points
The following questions regard information about your potential involvement with
substance abuse during the past 12 months. Please answer the following questions yes or no.
1. Have you used drugs other than those required for medicinal purposes? 2. Have you taken higher doses of drug prescribed to you? 3. Do you take more than one drug/alcohol at a time? 4. Can you get through a week without using any drug/alcohol? 5. Are you able to stop using drugs/drinking when you want to? 6. Have you had “blackouts” as a result of drug/alcohol use? 7. Do you ever feel bad or guilty after a night of drug/alcohol use? 8. Do your parents, friends, teammates, coaches, significant other ever complain about 9. Have drugs /alcohol ever created a problem between you, parents, friends, 10. Have you lost friends because of your drug/alcohol use? 11. Have you been in trouble at school/work/athletics due to drug/alcohol use? 12. Have you ever gotten in fights under the influence of drugs/alcohol? 13. Have you ever ingaged in an illegal activity to obtain drugs/alcohol? 14. Have you ever been arrested for any drug/alcohol related issues? 15. Have you ever experienced drug/alcohol withdrawl symptoms when you stopped 16. Have you had to seek medical attention due to drug/alcohol use? 17. Have you gone to anyone for help with drug/alcohol problem? 18. Have you ever been involved in a treatment program specifically related to Scoring:
“No” responses = 0
Questions 4 and 5 the scoring will be reversed ( yes= 0, no =1) 1-5 points= low risk of substance abuse problem 6-10= moderate risk of substance abuse problems 11-15= substantial risk of substance abuse problem 16-above= severe risk of substance abuse problem Website: Montgomery County Court Referral Program Retrieved June 16, 2001

Source: http://users.rowan.edu/~capano66/Assessment.pdf