Name: Date of birth:  

Please complete the following sections for each substance listed and include any applicable information:

Alcohol:

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/Snort Smoke Inject Other Not applicable

Date of last use:  

Average drinks per drinking day:  

In the last 30 days, how often have you had:

For females, 4 of more drinks on one occasion  

For males, 5 or more drinks on one occasion:  

 

Heroin, Fentanyl, or Other Non-Prescription Opioids:

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/Snort Smoke Inject Other Not applicable

 

Date of last use:  

 

Prescription Opioid Medication Misuse:

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other Not applicable

 

Specify type:  

Were these medications from a valid prescription?

 

Date of last use:  

 

Benzodiazepines/Other Sedatives/Hypnotics/Sleeping Medication Misuse:

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other Not applicable

 

Were these medications from a valid prescription? YesNo

 

Date of last use:  

 

Cocaine/Crack:

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/Snort Smoke Inject Other Not applicable

 

Date of last use:  

 

Methamphetamine/Other Stimulants:

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other Not applicable

 

Date of last use:  

 

Prescription Stimulant Misuse:

Frequency of use:  Never used No use in the past 30 days 3 or less days/month 1-3 days/week 4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other Not applicable

 

Specify type:  

Were these medications from a valid prescription? YesNo

 

Date of last use:  

 

Misuse of Other Prescription Drugs:

Frequency of Use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other Not applicable

 

Specify type:  

Date of last use:  

 

Cannabis or Marijuana:

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other Not applicable

 

Date of last use:  

 

Nicotine or Tobacco:

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other Not applicable

 

Date of last use:  

 

Other Drugs:

Other Drug 1:  

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other

 

Date of last use:  

 

Other Drug 2:  

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other

 

Date of last use:  

 

Other Drug 3:  

Frequency of use: Never usedNo use in the last 30 days3 or less days/month1-3 days/week4-7 days/week

 

Duration of continuous use:  

Method of intake:  Oral Nasal/snort Smoke Inject Other

 

Date of last use: