CRAFFT Form | Storybook Pediatrics

CRAFFT Form (Select Appropriate Clinic)

For which clinic is this form?

Storybook Pediatrics

G. F. Still ADHD Clinic

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Date

Patient *

DOB *

(MM/DD/YYYY)

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