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


the Way he/she Looks

the Way he/shes treated by others

work or school environment

the marriage

the relationship

Has Lost Interest in:





other interests

Lies or is Evasive about Outside Activities

Steals Money or Misuses Money

Neglects Responsibilities Toward:

Brothers or Sisters


Other Family

Are Other Addicted Persons:

Living with Subject?

Working with Subject?

Going to School with Subject?