Opioid Risk Assessment

The reason for these questions is to help you know if you are at risk for opioid misuse. The results are only for you. No one else will see the results. This survey will not be recorded in any way.

Mark yes or no to each question  
 
Do you have a history of alcohol or drug problems?:

Do you have a parent or grandparent with alcohol or drug problems?:

Are you under age 21 or over age 65?:

Have you had a traumatic event in your life as a child or adult?:

Have you ever had an opioid overdose?:

Do you have mental health challenges? (depression, anxiety, bipolar disorder, schizophrenia, PTSD, etc.)?:

Do you have trouble finding a place to live?:

Do you have trouble finding food for you or your family?: