Substance Use Screen
Date:
-
Month
-
Day
Year
Name:
First Name
Middle Initial
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Drug:
*
Age of first use:
*
Date of last use:
*
Frequency of current use in past 6 months:
*
Add another substance?
Drug:
Age of first use:
Date of last use:
Frequency of current use in past 6 months:
Add another substance?
Drug:
Age of first use:
Date of last use:
Frequency of current use in past 6 months:
Add another substance?
Drug:
Age of first use:
Date of last use:
Frequency of current use in past 6 months:
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What drug(s) are you seeking treatment for?
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