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Community & Family Resources
Phone 515-576-7261
Fax 515-955-7628
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* 1. Have you used drugs other than those required for medical reasons?
YES   NO  
* 2. Have you abused prescription drugs?
YES   NO  
* 3. Do you abuse more than one drug at a time?
YES   NO  
* 4. Can you get through the week without using drugs?
YES   NO  
* 5. Are you always able to stop using drugs when you want?
YES   NO  
* 6. Have you had “blackouts” or “flashbacks” as a result of drug use?
YES   NO  
* 7. Do you ever feel bad about your drug abuse?
YES   NO  
* 8. Does your spouse (or parents) ever complain about your involvement with drugs?
YES   NO  
* 9. Has drug abuse ever created problems between you and your spouse or your parents?
YES   NO  
* 10. Have you lost friends because of your use of drugs?
YES   NO  
* 11. Have you neglected your family because of your use of drugs?
YES   NO  
* 12. Have you been in trouble at work because of your use of drugs?
YES   NO  
* 13. Have you lost a job because of drug abuse?
YES   NO  
* 14. Have you gotten into fights when under the influence of drugs?
YES   NO  
* 15. Have you engaged in illegal activities in order to obtain drugs?
YES   NO  
* 16. Have you been arrested for possession of illegal drugs?
YES   NO  
* 17. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
YES   NO  
* 18. Have you had medical problems as a result of your drug use (ex: memory loss, hepatitis, convulsions, or bleeding)?
YES   NO  
* 19. Have you gone to anyone for help for a drug problem?
YES   NO  
* 20. Have you been involved in a treatment program specifically related to drug use?
YES   NO  
End of DAST
DAST Score:
0: None Reported
1-5: Low level
6-10: Moderate Level
11-15: Substantial Level
16-20: Severe Level
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