WHO-ASSIST_V3.0 Welcome to your WHO-ASSIST_V3.0 Name Email Phone INTERVIEWER ID INTERVIEWEE ID COUNTRY CLINIC Date NOTE: BEFORE ASKING QUESTIONS, GIVE ASSIST RESPONSE CARD TO PATIENT Question 1 (if completing follow-up please cross-check the patient’s answers with the answers given for Q1 at baseline. Any differences on this question should be queried) In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY) 1a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) Tobacco products (cigarettes, chewing tobacco, cigars, etc.) No Yes None 1b. Alcoholic beverages (beer, wine, spirits, etc.) Alcoholic beverages (beer, wine, spirits, etc.) No Yes None 1c. Cannabis (marijuana, pot, grass, hash, etc.) Cannabis (marijuana, pot, grass, hash, etc.) No Yes None 1d. Cocaine (coke, crack, etc.) Cocaine (coke, crack, etc.) No Yes None 1e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) No Yes None 1f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) Inhalants (nitrous, glue, petrol, paint thinner, etc.) No Yes None 1g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) No Yes None 1h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) No Yes None 1i. Opioids (heroin, morphine, methadone, codeine, etc.) Opioids (heroin, morphine, methadone, codeine, etc.) No Yes None 1j. Other - specify: Others - specify: No Yes None Comment Probe if all answers are negative:“Not even when you were in school?”If "No" to all items, stop interview.If "Yes" to any of these items, ask Question 2 foreach substance ever used. Question 2 In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)? 2a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) Tobacco products (cigarettes, chewing tobacco, cigars, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 2b. Alcoholic beverages (beer, wine, spirits, etc.) Alcoholic beverages (beer, wine, spirits, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 2c. Cannabis (marijuana, pot, grass, hash, etc.) Cannabis (marijuana, pot, grass, hash, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 2d. Cocaine (coke, crack, etc.) Cocaine (coke, crack, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 2e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 2f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) Inhalants (nitrous, glue, petrol, paint thinner, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None Comment 2g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 2h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 2i. Opioids (heroin, morphine, methadone, codeine, etc.) Opioids (heroin, morphine, methadone, codeine, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 2j. Other - specify: Other - specify: Never Once or Twice Monthly Weekly Daily or almost Daily None Comment If "Never" to all items in Question 2, skip to Question 6.If any substances in Question 2 were used in the previous three months, continue with Questions 3, 4 & 5 for each substance used. Question 3 During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, ETC)? 3a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) (cigarettes, chewing tobacco, cigars, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3b. Alcoholic beverages (beer, wine, spirits, etc.) (beer, wine, spirits, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3c. Cannabis (marijuana, pot, grass, hash, etc.) (marijuana, pot, grass, hash, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3d. Cocaine (coke, crack, etc.) (coke, crack, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) (nitrous, glue, petrol, paint thinner, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) (Valium, Serepax, Rohypnol, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) (LSD, acid, mushrooms, PCP, Special K, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3i. Opioids (heroin, morphine, methadone, codeine, etc.) (heroin, morphine, methadone, codeine, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 3j. Other - specify: Others - specify: Never Once or Twice Monthly Weekly Daily or almost Daily None Comment Question 4 During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems? 4a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) (cigarettes, chewing tobacco, cigars, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4b. Alcoholic beverages (beer, wine, spirits, etc.) (beer, wine, spirits, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4c. Cannabis (marijuana, pot, grass, hash, etc.) (marijuana, pot, grass, hash, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4d. Cocaine (coke, crack, etc.) (coke, crack, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4i. Opioids (heroin, morphine, methadone, codeine, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 4.j. Other - specify: (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None Comment Question 5 During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)? Hint 5a. Tobacco products (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 5b. Alcoholic beverages (beer, wine, spirits, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 5c. Cannabis (marijuana, pot, grass, hash, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None d. Cocaine (coke, crack, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 5e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 5f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 5g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 5h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 5i. Opioids (heroin, morphine, methadone, codeine, etc.) (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None 5j. Other - specify: (speed, diet pills, ecstasy, etc.) Never Once or Twice Monthly Weekly Daily or almost Daily None Ask Questions 6 & 7 for all substances ever used (i.e. those endorsed in Question 1) Hint Question 6 Has a friend or relative or anyone else ever expressed concern about your use of(FIRST DRUG, SECOND DRUG, ETC.)? Hint 6a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6b. Alcoholic beverages (beer, wine, spirits, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6c. Cannabis (marijuana, pot, grass, hash, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6d. Cocaine (coke, crack, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6i. Opioids (heroin, morphine, methadone, codeine, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 6j. Other – specify: (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None Comment Question 7 Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)? Hint 7a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7b. Alcoholic beverages (beer, wine, spirits, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7c. Cannabis (marijuana, pot, grass, hash, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7d. Cocaine (coke, crack, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7f. Inhalants (nitrous, glue, petrol, paint thinner, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7i. Opioids (heroin, morphine, methadone, codeine, etc.) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None 7j. Other – specify: (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None Comment Question 8 Hint Have you ever used any drug by injection? (NON-MEDICAL USE ONLY) (speed, diet pills, ecstasy, etc.) No, Never Yes, in the past 3 months Yes, but not in the past 3 months None IMPORTANT NOTE:Patients who have injected drugs in the last 3 months should be asked about their pattern of injecting during this period, to determine their risk levels and the best course of intervention. PATTERN OF INJECTING INTERVENTION GUIDELINES Once weekly or less or Fewer than 3 days in a row Brief Intervention including “risks associated with injecting” card More than once per week or 3 or more days in a row Further assessment and more intensive treatment* Hint Time's up Leave a Reply Cancel replyCommentEnter your name or username to comment Enter your email address to comment Enter your website URL (optional) Save my name, email, and website in this browser for the next time I comment.
