• Behavioral Questionnaire

    CONFIDENTIAL

  • Instructions: Please complete the questionnaire below. The form is not complete until it is signed, dated, and submitted.

  • Please answer YES or NO to the following questions. For questions in which you have answered YES, you MUST EXPLAIN. In your explanation, you MUST PROVIDE DETAILED INFORMATION including specific circumstances, dates, and status of situation. 

  • Behavioral Questionnaire

    All questions require a response.

  • Behavioral Questionnaire

    All questions require a response.

  • Behavioral Questionnaire

    All questions require a response.

  • Please specify date drug was first used, date drug was last used, and the total number of times drug was used. Put N/A if it does not apply to you.

  • Behavioral Questionnaire

    All questions require a response.

  • Behavioral Questionnaire

    All questions require a response.

  • Behavioral Questionnaire

    All questions require a response.

  • Behavioral Questionnaire

    All questions require a response.

  • Behavioral Questionnaire

    All questions require a response.

  • SCENARIOS

    Please answer the following questions. All questions require a response.

  • SIGNATURE

  • I attest that what I have written/endorsed on this questionnaire is true.

  • Clear
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