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Substance Use Screening Form - Alternative

Confidential screening tool to assess alcohol, tobacco, and drug use patterns for clinical review.

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Confidential screening tool to assess alcohol, tobacco, and drug use patterns for clinical review.

Patient Name*

How often do you have a drink containing alcohol?*

Do you currently use tobacco products?*

Yes, dailyYes, occasionallyNo, but I used toNever

Have you used any of the following in the past 12 months? (select all that apply)

Cannabis / MarijuanaPrescription opioids (not as prescribed)Stimulants (cocaine, methamphetamine)Sedatives or tranquilizersNone of the above

Have you ever felt you should cut down on your substance use?*

YesNo

Are you currently in any treatment or recovery program?*

YesNo

Additional notes or context you would like to share

Fields7

Uses0

healthcaresubstance-usescreeningbehavioral-healthaddiction