| Yes No | |
| Do you ever use more cocaine than you planned? | |
| Has the use of cocaine interfered with your job? | |
| Is your cocaine use causing conflict with your spouse or family? | |
| Do you feel depressed, guilty, or remorseful after you use cocaine? | |
| Do you use whatever cocaine you have almost continuously until the supply is exhausted? | |
| Have you ever experienced sinus problems or nosebleeds due to cocaine use? | |
| Do you ever wish that you had never taken that first line, hit, or injection of cocaine? | |
| Have you experienced chest pains or rapid or irregular heartbeats when using cocaine? | |
| Do you have an obsession to get cocaine when you don't have it? | |
| Are you experiencing financial difficulities due to your cocaine use? | |
| Do you experience an anticipation high just knowing you are about to use cocaine? | |
| After using cocaine, do you have difficulty sleeping without taking a drink or another drug? | |
| Are you absorbed with the thought of getting loaded even while interacting with a friend or loved one? | |
| Have you begun to use drugs or drink alone? | |
| Do you ever have feelings that people are talking about you or watching you? | |
| Do you use larger doses of drugs or alcohol to get the same high you once experienced? | |
| Have you tried to quit or cut down on your cocaine use only to find that you couldn't? | |
| Have any of your friends or family suggested that you may have a problem? | |
| Have you ever lied to or misled those around you about how much or how often you use? | |
| Do you use drugs in your car, at work, in the bathroom, on airplanes, or other public places? | |
| Are you afraid that if you stop using cocaine or alcohol your work will suffer or you will lose your energy, motivation, or confidence? | |
| Do you spend time with people or in places you otherwise would not be around but for the availability of drugs? | |
| Have you ever stolen drugs or money from friends or family? |
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