Signs and Symptons Scale

Section I: Qualities of a Parent or Sponsor

Have you had experience with substance abusers?





Have you read literature on substance abuse?





Are you familiar with the psychological effects of the common substances of abuse?





Are you familiar with the physical effects of the common substances of abuse?





Are you familiar with the social effects of the common substances of abuse?





Are you familiar with the most common forms of treatment for substance abuse?





Have you discussed drug abuse with your children?





Have you condemned drug abuse?





Have you expressed your dislike for your children's friends who you know or suspect are using drugs?





Have you told your family that drug use will not be accepted in your home?





Have you asked for their help in keeping drugs out of the home?





Have you been careful not to use drugs in front of your children?





Have you been careful not to let your children see you high or drunk?





Have you told your children that you love them?





Do you set time aside to listen and discuss problems with your children?





Do you spend time together as a family?





Do you spend time with your spouse?





Do you listen to your spouses problems?





Are you supportive of your spouse's interests and problems?





Do they know that you care for them?





Do you provide for your family?





Do you make sacrifices for your children?





Do you make sacrifices for your spouse?





Section II: Qualities of the Home

Do people in the home have trouble getting along?





Are there arguments in the home between parents?





Are there arguments in the home between other family members?





Is there negative tension in the home?





Is there physical violence in the home?





Are there people in the family who use drugs?





Are there family members who sell drugs?





Are there family members who have drug abuser friends calling or coming by the house?





Is there verbal abuse and cursing in the home?





Are there healthy adults in the house who are not working?





Have children in the family dropped out of school?





Have family members been allowed to get high in the house?





Have family members been allowed to sell or purchase drugs in the house?





Have minors been out past 9:00 pm without calling or an adult knowing where they are?





Are minors allowed to associate with whoever they want?





Are children made to feel uncomfortable at home?





Are adults in the family made to feel uncomfortable at home?





Is there disrespect among family members?





Is there little support for each other among family members?





Are relationships between family members weak?





Section III: General Indicators - For Subject

Medical Problems





Psychological Problems





Social Problems





Emotional Problems





Educational Problems





Legal Problems





Section IV: Qualities of Mental Health - For Subject

Problems Eating





Problems Losing Weight





Problems Getting to Sleep





Has Mood Swings





Has Sad Moods





Is Nervous





Is Irritable





Has a Quick Temper





Laugh a Great Deal





Cry a Great Deal





Talks about Suicide





Is Verbally Threatening to Others





Disrespectful towards Authority





Thinks Everyone is Against Him/Her





Believes Things That Are Not True





Been Treated for a Mental Problem





Has a Bad Attitude about Life





Not Care About School or Work





Has Trouble Remembering Things





Problems with Memory





Has Shakes and Tremors





Has Headaches





Has Dizziness





Has Blackouts





Has Seizures





See Things that are Not There





Talks to self





Talks to People that No one Else Sees





Is Very Sensitive or Easily Offended





Is Fidgety or Restless





Is Slow and Listless





Section V: Qualities of Personal Relationship - For Subject

Is Detached and Withdrawn





Comes Home Late from Work or School





Comes Home After 10:00 PM





Hangs Out with Friends Until Very Late





Oversleeps in the Morning





Is Late for School or Work





Is Absent from School or Work





Has Disagreements with Teachers and Supervisors





Has Difficulty Maintaining a Job, staying in school





Comes Home Late on Payday





Comes Home Intoxicated





Spends Large Amounts from Paycheck





Does Not Bring Paycheck Home





Associates with Undesirable Friends





Has Relationship with Another Man Or Woman





Is Verbally Abusive





Is Physically Abusive





Is Sexually Inactive with Spouse





Friends Call or Come by Late at Night Without Being Introduced





Does Not Come Home on Pay day





Section VI: Qualities of Addictive Behavior - For Subject

Is Unfriendly Toward Others





Avoids Conversations





Sweats a Great Deal When Talking





Seems Manipulated by Others





Is Sexually Seductive





Attempts to Take Control





Is Evasive When Asked Direct Questions about Drugs





Is Suspicious of Others





Rarely Makes Sense





Has unclear Thoughts





Exercises Poor Judgment





Rarely Gives Clear Answers to Questions





Has Short Attention Span





Is Fearful or Scared





Is Easily Influenced by Friends





Has Lost Interest in personal Appearance





Has Lost Interest in their Work or School





Talks about Drugs





Has History of Using Drugs





Believes he/she can Associate with Addicts and Not Use Drugs





Believes he/she can Use Drugs and can Stop when he/she Wants





Claims to want to use drugs to help:

Overcome Emotional Pain





Overcome Physical Pain





Lose Weight





Sleep





the Way he/she Looks





the Way he/shes treated by others





work or school environment





the marriage





the relationship





Has Lost Interest in:

work





school





family





friends





other interests





Lies or is Evasive about Outside Activities





Steals Money or Misuses Money





Neglects Responsibilities Toward:

Brothers or Sisters





Children





Other Family





Are Other Addicted Persons:

Living with Subject?





Working with Subject?





Going to School with Subject?