Loading...

Templates Free Tools Guides Contact Us

Sign in Get Started

Templates Free Tools Guides Contact Us Privacy Terms

© 2026 ZenBuild. All rights reserved.

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

Templates→Healthcare→Substance Use Screening Form

Substance Use Screening Form

Confidential screening tool to assess alcohol, tobacco, and drug use as part of routine primary care or behavioral health intake. Supports early intervention referrals.

0.0 (0 ratings)

Sign in to rate this template

Preview

READ-ONLY MODE

Substance Use Screening Form

Your answers are confidential and help us provide the best possible care. Please answer honestly.

Patient Name*

Do you currently use tobacco products?*

No, neverFormer userYes — cigarettesYes — e-cigarettes/vapingYes — other tobacco

How often do you drink alcohol?*

NeverMonthly or less2–4 times per month2–3 times per week4 or more times per week

In the past year, have you used recreational drugs or used prescription drugs in a way not prescribed?*

NoYes

Have you ever felt you should cut down on your drinking or drug use?

YesNo

Are you interested in information or support for reducing substance use?

YesNoMaybe

Additional Comments

Template Details

CategoryHealthcare

IndustryHealthcare

Fields7

Uses0

Views0

healthcaresubstance usebehavioral healthaddictionscreening