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Practice name: ______________________________
DAST-10 Drug Abuse Screening Test
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?
Feel guilty about drug use?
Additional details
Spouse or family complains about drug use?
Neglected family or responsibilities?
Engaged in illegal activities for drugs?
Withdrawal symptoms from drugs?
Medical problems from drug use?
DAST-10 Total Score
Severity Level
DAST-10 Drug Abuse Screening Test template from formisoft.com. formisoft.com/intake-templates/dast-drug-abuse-screening