• Jordan West Family Counseling

    Adult History Questionnaire- Substance Use

  • Court Orders Clients

  • Date of Birth*
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  • 1. Please use the following code to report your use of any of the following substances in the past 12 months:

    1 = every day
    2 = 5 to 6 days per week
    3 = 3 to 4 days per week
    4 = 1 to 2 days per week
    5 = At least 12 times per year
    6 = Fewer than 12 times per year
    7 = Never used

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  • When did you last use any of the following substances? Code use according to the following:

    • 1 = within the past day
    • 2 = 2 to 7 days
    • 3 = 8 to 30 days
    • 4 = 1 to 6 months
    • 5 = 7 to 12 months
    • 6 = more than one year
    • 7 = never used
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  • Please use the following code to indicate your use of the following substances in your entire lifetime:

    1 = every day
    2 = 5 to 6 days per week
    3 = 3 to 4 days per week
    4 = 1 to 2 days per week
    5 = At least 12 times per year
    6 = Fewer than 12 times per year
    7 = Never used

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  • Do you have a primary physician?*
  • Do you have any other physicians who are currently treating you?*
  • Do you have any allergies to the environments?*
  • Do you have any allergies to medications?*
  • Are you currently taking any medications?*
  • Are you taking the medication as prescribed by your physician?*
  • Are you taking any vitamins or supplements?*
  • Do you have any current health concerns?*
  • Have you ever, during your life, had any significant health concerns?*
  • Have you ever been hospitalization(s) or visit(s)?*
  • Do you have a current dentist?*
  • Have you ever had any dental problems?*
  • Check if a physician ever talked with you about:
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  • Are you currently involved in counseling?*
  • Have you engaged in counseling in the past?*
  • Have you ever been hospitalized for mental health reasons?*
  • Have you ever thought about or attempted self-harm?*
  • Have you ever been involved in a physical fight since you were 18 year old?*
  • Have you ever been arrested?*
  • Have you ever received a DWI or DUI citation?*
  • Have you ever physically struck another person or object?*
  • Have you ever been harmed or been afraid of someone you lived with or were close to?*
  • Have you ever been required to have a substance abuse assessment?*
  • Have you been terminated due to substance use/abuse?*
  • Have you ever been placed on a “Last Chance Agreement?”*
  • Have you avoided a job because you would have to complete a drug screen?*
  • Have you had a work-related driving offense in the last 10 years?*
  • Have you been involved in co-worker conflicts?*
  • Have you ever failed to complete a job probationary period?*
  • Have you ever had driving offenses due to substance use?*
  • Have you been arrested due to use or selling of illegal substances?*
  • Do you gamble?*
  • Do you have any problematic spending habits?*
  • Have you ever filed bankruptcy?*
  • Have you ever had your wages garnished?*
  • Is someone requiring that you complete this assessment? Check all that apply>
  • Do you believe that you have a drug or alcohol problem?*
  • Do you believe that you can benefit from substance abuse treatment?*
  • Have you ever received treatment for a substance abuse problem?*
  • If you received treatment for a substance abuse, please answer the following questions:
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  • Do you keep alcohol or drugs in your home?*
  • Are there many drugs or alcohol in your work environment?*
  • Do many of your friends use drugs or alcohol?*
  • Does your current or past partner use drugs or alcohol?*
  • Do you believe that it is OK to use drugs or alcohol?*
  • Living arrangements:
  • Do you have a high school diploma or GED?*
  • Do you have any other specialized Training?*
  • Do you have a college education?*
  • Do you have any learning disabilities?*
  • Do you have a spiritual belief system?*
  • Do you have a specific culture that you identify with?*
  • I have provided the following documents to assist in the development of this assessment:*
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  • I have completed this questionnaire and I verify that my answers are accurate.

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