Do you have difficulty in refusing cocaine when it is offered to you?
yes
no

Have you ever used more cocaine than you planned?
yes
no

Have you ever tried to stop or reduce your cocaine use and found that you have not been able to?
yes
no

Do you use larger quantities of cocaine to get the same high that you previously experienced?
yes
no

Do you need to be on a 'cocaine high' to have a good time?
yes
no

Do you worry that you will not function as well with out cocaine?
yes
no

Do you tend to continue using cocaine until your supplies are gone even if you planned to save some for the morning?
yes
no

Have you ever been on a binge lasting more than 24 hours?
yes
no

Do you ever feel guilty about your cocaine use?
yes
no

Have others ever expressed concern about your cocaine use?
yes
no

Do you crave cocaine when exposed to people places and objects that you associate with use?
yes
no

Do you use cocaine alone?
yes
no

Do you use more cocaine than you can afford?
yes
no

Has anyone ever commented that that your behaviour or personality has changed?
yes
no

Do you ever lie to yourself or other's or make excuses about your cocaine use?
yes
no

Do you conceal the extent of your cocaine use from fiends and family?
yes
no

Is cocaine having a negative affect on your mental state?
yes
no

Is cocaine affecting your physical health?
yes
no

Is cocaine use affecting your sex life?
yes
no

Is cocaine use affecting your career?
yes
no

Do you play down the severity of your cocaine habit?
yes
no

Are you sometimes preoccupied with thoughts about cocaine?
yes
no

Do you use cocaine at work?
yes
no

Do you ever experience an overwhelming compulsion to use cocaine?
yes
no

Have you ever experienced sinus problems or nose bleeds from your cocaine use?
yes
no

Do you have an obsession with cocaine when you don't have any?
yes
no

Have you ever had chest pains or experienced irregular heart beats when using cocaine?
yes
no

Do your ever think that your are being watched or followed or that there is a conspiracy against you?
yes
no

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