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Substance Abuse Screening Form - Free Healthcare Template | ZenBuild | ZenBuild

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Substance Abuse Screening Form

Conducts a confidential screening for substance use disorders to guide treatment planning.

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Substance Abuse Screening Form

Conducts a confidential screening for substance use disorders to guide treatment planning.

Patient Full Name*

Date of Birth*

Substances used in the past 12 months (check all that apply)

AlcoholCannabisPrescription opioids (non-prescribed)Stimulants (cocaine, methamphetamine)Sedatives / benzodiazepinesTobacco / nicotineOther

How often do you use alcohol or other substances?*

Have substance use problems caused difficulties in your life?*

YesNo

Have you ever received treatment for substance use?*

YesNo

Are you interested in receiving support or treatment?*

YesMaybeNo

Additional information you would like to share (confidential)

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

Uses0

Views3

healthcaresubstance abusescreeningaddictionmental health