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ASSIST Substance Use Screen

This substance use screening may be used to identify substance use and related problems. Please answer all questions as honestly and openly as possible. If you are taking this on behalf of a loved one, please note that all of these questions will be phrased as if that person were taking this screening. If suggested, contact us as soon as you can.

Please note, this screening does not serve as a diagnosis tool but can aid your clinician in determining our recommended course of action.

In your life, which of the following substances have you ever used? (Non-medical use only.) Check all that apply.a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)b. Alcoholic beverages (beer, wine, spirits, etc.)c. Cannabis (marijuana, pot, grass, hash, etc.)d. Cocaine (coke, crack, etc.)e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)i. Opioids (heroin, morphine, methadone, codeine, etc.)j. Other

In the past three months, how often have you used the substance(s) you checked?

Tobacco products (cigarettes, chewing tobacco, cigars, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Alcoholic beverages (beer, wine, spirits, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Cannabis (marijuana, pot, grass, hash, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Cocaine (coke, crack, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Inhalants (nitrous, glue, petrol, paint thinner, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Opioids (heroin, morphine, methadone, codeine, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Other *NeverOnce or TwiceWeeklyDaily or Almost Daily

During the past three months, how often have you had a strong desire or urge to use the substance(s) you checked?

Tobacco products (cigarettes, chewing tobacco, cigars, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Alcoholic beverages (beer, wine, spirits, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Cannabis (marijuana, pot, grass, hash, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Cocaine (coke, crack, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Inhalants (nitrous, glue, petrol, paint thinner, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Opioids (heroin, morphine, methadone, codeine, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Other *NeverOnce or TwiceWeeklyDaily or Almost Daily

During the past three months, how often has your use of the below substance(s) led to health, social, legal or financial problems?

Tobacco products (cigarettes, chewing tobacco, cigars, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Alcoholic beverages (beer, wine, spirits, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Cannabis (marijuana, pot, grass, hash, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Cocaine (coke, crack, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Inhalants (nitrous, glue, petrol, paint thinner, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Opioids (heroin, morphine, methadone, codeine, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Other *NeverOnce or TwiceWeeklyDaily or Almost Daily

During the past three months, how often have you failed to do what was normally expected of you because of your use of the below substance(s)?

Tobacco products (cigarettes, chewing tobacco, cigars, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Alcoholic beverages (beer, wine, spirits, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Cannabis (marijuana, pot, grass, hash, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Cocaine (coke, crack, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Inhalants (nitrous, glue, petrol, paint thinner, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Opioids (heroin, morphine, methadone, codeine, etc.) *NeverOnce or TwiceWeeklyDaily or Almost Daily

Other *NeverOnce or TwiceWeeklyDaily or Almost Daily

Has a friend or relative or anyone else ever expressed concern about your use of the below substance(s)?

Tobacco products (cigarettes, chewing tobacco, cigars, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Alcoholic beverages (beer, wine, spirits, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Cannabis (marijuana, pot, grass, hash, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Cocaine (coke, crack, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Inhalants (nitrous, glue, petrol, paint thinner, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Opioids (heroin, morphine, methadone, codeine, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Other *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Have you ever tried and failed to control, cut down or stop using the below substance(s)?

Tobacco products (cigarettes, chewing tobacco, cigars, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Alcoholic beverages (beer, wine, spirits, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Cannabis (marijuana, pot, grass, hash, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Cocaine (coke, crack, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Inhalants (nitrous, glue, petrol, paint thinner, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Opioids (heroin, morphine, methadone, codeine, etc.) *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

Other *No, NeverYes, in the past 3 monthsYes, but not in the past 3 months

TotalThis instrument is designed for screening purposes only and is not to be used as a diagnostic tool.

Your Score

0 - 3 > None/Minimal

Action – None

Your Score

3.01 – 26 > Mild/Watchful

Action – Please schedule a consultation with Dr. Cruz or your physician.

Your Score

26.01 or Higher > Moderate/Severe Treatment

Action – Please schedule a consultation with Dr. Cruz or your physician.

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SCORE

0 – 3 > None-minimal

ACTION – None

3.01 – 26 > Mild

ACTION – Please schedule a consultation with Dr. Cruz or your physician.

26.01 or higher > Moderate/Severe Treatment Recommended

ACTION – Please schedule a consultation with Dr. Cruz or your physician.

Sources

Humeniuk RE, Ali RA, Babor TF, Farrell M, Formigoni ML, Jittiwutikarn J, Boerngen de Larcerda R, Ling W, Marsden J, Monteiro M, Nhiwhatiwa S, Pal H, Poznyak V & Simon S (2008). Validation of the Alcohol Smoking and Substance Involvement Screening Test (ASSIST). Addiction 103(6): 1039-1047
For more information, visit: https://www.who.int/publications/i/item/978924159938-2

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