Patient CRAFFT PHQ CRAFFT PHQ Storybook Patients CRAFFT & PHQ Forms (to be completed by Patient and NOT Parent) Date * Patient Name * Date of Birth * CRAFFT Form During the PAST 12 MONTHS, on how many days did you: 1. Drink more than a few sips of beer, wine, or any drink containing alcohol? Put “0” if none. * 2. Use any marijuana (cannabis, weed, oil, wax, or hash by smoking, vaping, dabbing, or in edibles) or “synthetic marijuana” (like “K2,” “Spice”)? Put “0” if none * 3. Use anything else to get high (like other illegal drugs, pills, prescription or over-the-counter medications, and things that you sniff, huff, vape, or inject)? Put “0” if none. * Please answer the following also. 4. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs? No Yes 5. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? No Yes 6. Do you ever use alcohol or drugs while you are by yourself, or ALONE? No Yes 7. Do you ever FORGET things you did while using alcohol or drugs? No Yes 8. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? No Yes 9. Have you ever gotten into TROUBLE while you were using alcohol or drugs? No Yes PHQ-9 Form Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things Not at all Several Days More than half the days Nearly every day 2. Feeling down, depressed, or hopeless Not at all Several Days More than half the days Nearly every day 3. Trouble falling or staying asleep, or sleeping too much Not at all Several Days More than half the days Nearly every day 4. Feeling tired or having little energy Not at all Several Days More than half the days Nearly every day 5. Poor appetite or overeating Not at all Several Days More than half the days Nearly every day 6. Feeling bad about yourself—or that you are a failure or have let yourself or your family down Not at all Several Days More than half the days Nearly every day 7. Trouble concentrating on things, such as reading the newspaper or watching television Not at all Several Days More than half the days Nearly every day 8. Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual Not at all Several Days More than half the days Nearly every day 9. Thoughts that you would be better off dead or of hurting yourself in some way Not at all Several Days More than half the days Nearly every day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not at all difficult Somewhat difficult Very difficult Extremely difficult If you are human, leave this field blank. Submit
