The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Required format:

STOP Order Form

South Texas Overdose Prevention is a public health program that will expand and enhance overdose prevention and other harm reduction services and activities for minority individuals with, or at risk of developing substance use disorders (SUD). All services offered are for FREE. Services provided include: screening, substance use education/intervention, referral to treatment, recovery support services, and distribution of Naloxone Nasal Spray, wound care kits, sharps disposal containers and safe sex kits.

To qualify for services individuals must meet the following criteria:
• Must be 18 years old or older
• Live in one of the following counties: Atascosa, Bandera, Bexar, Calhoun, Comal, Dewitt, Dimmit, Edwards, Frio, Gillespie, Goliad, Gonzales, Guadalupe, Jackson, Karnes, Kendall, Kerr, Kinney, La Salle, Lavaca, Maverick, Medina, Real, Victoria, Uvalde, Val Verde, Wilson, or Zavala
• Currently use or have a history of substance use (alcohol or drugs) in the past 12 months
• Have a history of overdose in the past 36 months
• Friend/Family/Ally of someone using opioids

Please complete the survey and order form below. It should take approximately 5-10 minutes to complete.

Thank you!

Loading...

1. I am placing an order for

* must provide value

Myself

Family Member

Friend

Client/Patient

Not listed, specify

1a. Please specify who you are placing an order for or which agency/program you're with.

* must provide value

2. Are you 18 years or older?

* must provide value

Yes

No

2. Is the person you are ordering for 18 years or older?

* must provide value

Yes

No

3. Has the person used any drugs in the past 12 months or had an opioid overdose in the past 36 months?

* must provide value

Yes

No

3. Have you used any drugs in the past 12 months or had an opioid overdose in the past 36 months?

* must provide value

Yes

No

3a. Please specify

* must provide value

drug use in the past 12 months

opioid overdose in the past 36 months

3a. Please specify

* must provide value

drug use in the past 12 months

opioid overdose in the past 36 months

4. Which county do you live in?

* must provide value

4a. Please specify the county you live in.

Thank you for your interest. However, based on the information you've provided, here are some other resources and organizations that may be better able to assist you.

Corazon Ministries

http://corazonsa.org

UT Health-San Antonio

https://www.morenarcanplease.com/

Be Well Texas

https://bewelltexasclinic.org/

If you have any questions, please contact STOP's project manager, Adrienne Henze, at 210-358-6842 or Adrienne.Henze@uhs-sa.com.

About You

1. Which of the following best describes your gender?

* must provide value

Female

Male

Transgender

Non-Binary

Not listed, specify

1. Please specify your gender.

* must provide value

1a. What is your sexual orientation?

* must provide value

Straight or heterosexual

Bisexual

Gay/Lesbian

Queer, Pansexual and/or Questioning

Something else? Please specify

Refused

Please specify your sexual orientation.

* must provide value

2. What is your age?

* must provide value

3. Which of the following best describes your race? Select all that apply.

* must provide value

American Indian or Alaskan

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Not listed, specify

3a. Not listed race, specify

* must provide value

4. Which of the following best describes your ethnicity?

* must provide value

Hispanic, Latino/a, or Spanish Origin

Not Hispanic, Latino/a, or Spanish Origin

6. Do you know how to use Narcan (generic name Naloxone) (overdose reversal medication)?

* must provide value

Yes

No

What is Narcan (generic name Naloxone) (overdose reversal medication)?

General Instructions for the next set of questions:

"Drug use" refers to (1) the use of prescribed or over‐the‐counter drugs in excess of the directions, and (2) any nonmedical use of drugs.
The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin).
The questions do not include alcoholic beverages. Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.

Please enter today's date.

* must provide value

M-D-Y

These questions refer to drug use in the past 12 months. Please answer YES or NO.

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

* must provide value

Yes

No

2. Do you use more than one drug at a time?

* must provide value

Yes

No

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

* must provide value

Yes

No

4. Have you had "blackouts" or "flashbacks" as a result of drug use?

* must provide value

Yes

No

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

* must provide value

Yes

No

6. Do your spouse (or parents) ever complain about your involvement with drugs?

* must provide value

Yes

No

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

* must provide value

Yes

No

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

* must provide value

Yes

No

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

* must provide value

Yes

No

10. Have you had medical problems as a result of your drug use? (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?

* must provide value

Yes

No

DAST-10 Total Score

View equation

Interpretation of Score:

Score	Degree of Problems Related to Drug Use
0	No problems reported
1-2	Low level
3-5	Moderate level
6-8	High level
9-10	Severe level

You scored a ______. 6+ Severe Risk: Based on the provided answers, your score indicates a potential risk of health problems related to drug use and a possible moderate or severe substance use disorder. We encourage you to consider talking to your doctor, or contact us for guidance and support.

You scored a ______. No Problems Reported: Based on the provided answers, there are no problems with substance use.

You scored a ______. 1-2 At Risk: Based on the provided answers, your score indicates you may be at risk of developing a substance use disorder. We encourage you to continue to monitor your drug use. If your use of drugs increase or you experience a change in your mental health symptoms, consider contacting us for guidance and support.

You scored a ______. 3-5 Moderate Risk: Based on the provided answers, your score indicates a potential risk of health problems related to drug use and a possible mild or moderate substance use disorder. We encourage you to consider talking to your doctor, or contact us for guidance and support.

You scored a ______. 6+ Severe Risk: Based on the provided answers, your score indicates a potential risk of health problems related to drug use and a possible moderate or severe substance use disorder. We encourage you to consider talking to your doctor, or contact us for guidance and support.

Order

Please select the items that you want to order.

Narcan includes:

One (1) 4-mg dose of naloxone HCI nasal spray

Would you like to order Narcan (generic name Naloxone) (overdose reversal medication) at no cost to you?

* must provide value

Yes

No

Sharps container:

1 Sharps container

Would you like to order the sharps container at no cost to you?

* must provide value

Yes

No

Wound Care Kit Includes:

2 Bandaids

2 Ibuprofen

2 Non-Adherent Pads

2 Powder Free Gloves

2 Antiseptic Towlettes

2 Triple antibiotic ointment

Would you like to order the wound care kit at no cost to you?

* must provide value

Yes

No

Safe Sex Kit Includes:

1 Instuctions Card

2 Female Condoms

2 Dental Dams

5 KYNG

5 Non-Latex

5 Ultra Sensitive

5 Glow in the Dark

5 Red Trustex

5 Lubricants

Would you like to order the Safe Sex Kit at no cost to you? If you order the safe sex kit, you will be redirected to answer additional questions AFTER you submit your order.

Yes

No

Shipping Address Infomation

1. What is your first name?

* must provide value

2. What is your last name?

* must provide value

3. What is your street address?

* must provide value

4. What is your city?

* must provide value

5. What is your state?

* must provide value

TX

6. What is your zip code?

* must provide value

Additional Resources

1. Would you like a STOP staff member to reach out to you to provide additional assistance or resources?

* must provide value

Yes

No

2. What is your first name?

3. What is your last name?

4. Please provide the phone number where we can best reach you.

5. Please provide your email address.

6. Were you referred to STOP by someone?

* must provide value

Yes

No

6a. If yes, please tell us who and what program or organization they are from.

* must provide value

7. If you were not referred, how did you hear about us?

* must provide value

Housing Status

In the past 30 days, where have you been living most of the time? (do not read options)

Other (please specify)

Staff Only

1. Location of distribution

* must provide value

Other (please specify)

Which staff member is filling out this form?

What is the date of distribution

* must provide value

M-D-Y

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