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Have you used drugs other than those required for medical reasons? Yes No
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Do you use more than one drug at a time? Yes No
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Are you always able to stop using cocaine or other drugs when you want to? Yes No
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Have you had "blackouts" or "flashbacks" as a result of your cocaine use? Yes No
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Do you ever feel bad or guilty about your cocaine or drug use? Yes No
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Do others complain about your involvement with cocaine? Yes No
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Have you neglected your family because of your use of drugs? Yes No
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Have people ever confronted you or complained about your cocaine use? Yes No
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Have you ever missed work or a social occasion because of cocaine use? Yes No
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Has your cocaine use ever caused financial or legal problems? Yes No
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Is your cocaine use interfering with your sleep or causing irritability? Yes No
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Do you have to use more cocaine to get the same effects you once experienced? Yes No
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Have you ever had withdrawal symptoms, or felt sick, when you stopped using cocaine? Yes No