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Diagnosis Templat

Diagnosis Template:

Place a check in front of each symptom that is present

 Substance is taken in larger amounts or for longer periods than intended  A persistent desire or unsuccessful attempts to cut down or regulate substance use  A great deal of time spent obtaining the substance, using the substance, or recovering from

substance use  An intense desire or urge for the substance  Use results in failure to fulfill major obligations at work, home, or school  Continued use in spite of social or interpersonal problems caused or exacerbated by the

substance use  Important social, occupational, or recreational activities are given up or reduced because of the

substance use  Recurrent use in situations where it is physically hazardous  Continued use in spite of persistent or recurrent physical or psychological problems that occur as

a result of or exacerbated by substance use  Tolerance

 Need for more of the substance to achieve desired effect  Markedly diminished effect when using the same amount of the substance

 Withdrawal  Presence of characteristic withdrawal syndrome when the substance is not present  Using the substance to alleviate withdrawal symptoms

(Note: Criteria of tolerance and withdrawal are not considered to be met for those individuals taking medications under appropriate medical supervision)

Two or more checks on this list = substance use disorder


American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.


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