PSYCHOACTIVE DRUG HISTORY QUESTIONNAIRE (DHQ)

Client Name: ____________________________ Date: __________________ Gender: ______ SYD Number: __________

Drug Used
in past
12
mths
# of
days
used in
past 30
days*
Age of
first
use
How long
since last
use?**
Typical
amount
used each
day in last
30 days***
Method
of Use?
+

Stage of
Change
++
Clinical Comments
(Drug name, dosage patterns, periods of abstinence, used only
as prescribed, peer group usage, IV pattern, used prior to last 12
months etc).

Alcohol



INGEST




Cannabis


SMOKE




Heroin





Prescription Opiates
(codeine, morphine)


INGEST


Cocaine





Crack Cocaine



LSD


INGEST




Mushrooms


INGEST


Crystal Meth





Amphetamines/Ecstasy







GHB


INGEST


Drug Used
in past
12
mos
# of
days
used in
past 30
days
Age of
first
use
How long
since last
use**
Typical
amount
used each
day in last
30 days***
Method
of Use?
+
Stage of
Change
++
Clinical Comments
(Drug name, dosage patterns, periods of abstinence,
used only as prescribed, peer group usage, IV pattern,
used prior to last 12 months etc).

Benzodiazepine
(Valium, Sleeping pill)


INGEST




Dissociative Anesthetics
(Ketamine)

INGEST




PCP




Prescription Drugs


INGEST




Inhalants


INHALE





Other




Tobacco

SMOKE



*Reflect on the period of time and relate it to the youth. Are there memory-markers such as a holiday weekends, weekend patterns, celebrations like parties, sporting events, school
break, cultural celebrations, pay cheques etc. Look at a calendar and give youth opportunity to reflect.

**How long since last used: 24 hrs; 1-3 days; within last week; within last month; more than a month ago

***Question relates to the number of joints, pills, lines, injections, drinks, etc. used in a day. Do not ask amounts in terms of grams, ounces, points etc, or amount of money spent. For
alcohol use standardized measurements: 1 drink= 12 ounces of 5% beer; 5 ounces of 12% wine; 1.5 ounces of 40% liquor. i.e. 26oz of vodka per day = 17 drinks (17.3), a case of 12
beer = 12 drinks. If in doubt, ask a colleague or note it in clinical comments.

+ Indicate all methods of use i.e. smoke and snort cocaine. If IV use, elaborate in clinical comments

++Stage of Change: Pre-contemplative = PC / Contemplative = C / Determination/Preparedness = P / Action = A / Maintenance = M


30 day window: Start Date:________________________ End Date: (Day before entry to SYD)______________________

Completed By: __________________________________(please print)
1997, Centre for Addiction and Mental Health. Used with permission.