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MM ASAM Assessment Interview

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?

Yes

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:

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Timestamp

Audit

June 8, 2023 12:49 pm PDT

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June 8, 2023 3:17 pm PDT

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