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Run: DAST-10 Drug Use Screening and Follow-Up Form

Use this DAST-10 Drug Use Screening and Follow-Up Form to record screening context, capture the 10 responses, calculate the total score, and document next st...

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Screening Context

Screening Date (required)

Administered By (required)

Name or role of the person administering the screening.

Screening Setting (required)

Consent / disclosure provided before screening (required)

Confirm that the purpose of the screening and any PII collection were explained before the form was completed.

Yes No N/A

DAST-10 Responses

1. Have you used drugs other than those required for medical reasons? (required)

2. Do you abuse more than one drug at a time? (required)

3. Are you always able to stop using drugs when you want to? (required)

4. Have you had blackouts or flashbacks as a result of drug use? (required)

5. Do you ever feel bad or guilty about your drug use? (required)

6. Does your spouse, parent, or other close relative ever complain about your involvement with drugs? (required)

7. Have you neglected your family because of your use of drugs? (required)

8. Have you engaged in illegal activities in order to obtain drugs? (required)

9. Have you ever experienced withdrawal symptoms when you stopped taking drugs? (required)

10. Have you had medical problems as a result of your drug use? (required)

Scoring and Risk Level

Total DAST-10 Score (required)

Enter the total score from 0 to 10.

Risk Level (required)

Screening Summary

Brief clinical interpretation of the result, including any relevant observations.

Follow-Up Actions

Follow-up required? (required)

Recommended Follow-Up Actions

Follow-Up Notes

Document referrals, counseling provided, patient response, and any next appointment or handoff details.

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Email (required)

Your name (optional)

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