Do you use cocaine more than once per week?
Yes
No
Have you ever tried to stop using cocaine but couldn’t stay stopped?
Yes
No
Do you ever feel ashamed or guilty after using cocaine?
Yes
No
Have you ever lost a job due to cocaine use?
Yes
No
Do you find it challenging to control or reduce your cocaine use?
Yes
No
Have you experienced cravings or strong urges?
Yes
No
Does your cocaine use interfere with responsibilities at work, school, or home?
Yes
No
Do you spend a significant amount of time obtaining, using, or recovering from cocaine?
Yes
No
Have you given up activities you once enjoyed because of cocaine?
Yes
No
Do you experience withdrawal symptoms when not using cocaine?
Yes
No
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