CRAFFT+N Questionnaire "*" indicates required fields To be completed by Patient Date* MM slash DD slash YYYY Client name* First Last Date of Birth MM slash DD slash YYYY Please answer all questions honestly; your answers will be kept confidential.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? Say "0" if none. # of days*2. Use any marijuana (cannabis, weed, oil, wax, or hash by smoking, vaping, dabbing, or in edibles) or “synthetic marijuana” (like “K2,” “Spice”)? Say “0” if none. # of days*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)? Say “0” if none. # of days*4. Use a vaping device* containing nicotine and/or flavors, or use any tobacco products†? *Such as e-cigs, mods, pod devices like JUUL, disposable vapes like Puff Bar, vape pens, or e-hookahs. †Cigarettes, cigars, cigarillos, hookahs, chewing tobacco, snuff, snus, dissolvables, or nicotine pouches. Say "0" if none. # of days*READ THESE INSTRUCTIONS BEFORE CONTINUINGIf you put “0” in ALL of the boxes above, ANSWER QUESTION 5 BELOW, THEN STOPIf you put “1” or more for Questions 1, 2, or 3 above, ANSWER QUESTIONS 5-10 BELOWIf you put “1” or more for Question 4 above, ANSWER ALL QUESTIONS 5. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs? No Yes 6. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? No Yes 7. Do you ever use alcohol or drugs while you are by yourself, or ALONE? No Yes 8. Do you ever FORGET things you did while using alcohol or drugs? No Yes 9. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? No Yes 10. Have you ever gotten into TROUBLE while you were using alcohol or drugs? No Yes The following questions ask about your use of any vaping devices containing nicotine and/or flavors or use of any tobacco products. Select your answer for each question.1. Have you ever tried to QUIT using, but couldn’t? Yes No 2. Do you vape or use tobacco NOW because it is really hard to quit? Yes No 3. Have you ever felt like you were ADDICTED to vaping or tobacco? Yes No 4. Do you ever have strong CRAVINGS to vape or use tobacco? Yes No 5. Have you ever felt like you really NEEDED to vape or use tobacco? Yes No 6. Is it hard to keep from vaping or using tobacco in PLACES where you are not supposed to, like school? Yes No 7. When you HAVEN’T vaped or used tobacco in a while (or when you tried to stop using)…a. did you find it hard to CONCENTRATE because you couldn’t vape or use tobacco? Yes No b. did you feel more IRRITABLE because you couldn’t vape or use tobacco? Yes No c. did you feel a strong NEED or urge to vape or use tobacco? Yes No d. did you feel NERVOUS, restless, or anxious because you couldn’t vape or use tobacco? Yes No *References: Wheeler, K. C., Fletcher, K. E., Wellman, R. J., & DiFranza, J. R. (2004). Screening adolescents for nicotine dependence: the Hooked On Nicotine Checklist. J Adolesc Health, 35(3), 225–230; McKelvey, K., Baiocchi, M., & Halpern-Felsher, B. (2018). Adolescents’ and Young Adults’ Use and Perceptions of Pod-Based Electronic Cigarettes. JAMA Network Open, 1(6), e183535.NOTICE TO CLINIC STAFF AND MEDICAL RECORDS: The information on this page is protected by special federal confidentiality rules (42 CFR Part 2), which prohibit disclosure of this information unless authorized by specific written consent. © John R. Knight, MD, Boston Children’s Hospital, 2020. Reproduced with permission from the Center for Adolescent Behavioral Health Research (CABHRe), Boston Children’s Hospital. For more information and versions in other languages, see www.crafft.org
