Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
DAST-10 Drug Abuse Screening
Your information
Patient Name *
Date of Screening
____ / ____ / ________
Used drugs other than for medical reasons?
Abused prescription drugs?
Able to stop using drugs when you want?
Blackouts or flashbacks from drug use?
Additional details
Feel guilty about drug use?
Spouse or parents complain about drug use?
Neglected family because of drug use?
Engaged in illegal activities for drugs?
Withdrawal symptoms when stopping?
DAST-10 Total Score
DAST-10 Drug Abuse Screening template from formisoft.com. formisoft.com/intake-templates/dast-10-drug-screening