Hiawatha Valley Substance Abuse History Form Page 3
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6ALLERGIES
Have you ever had
Yes
No If Yes, please list below:
allergic reactions to
Name of Medication
Describe Allergic Reaction
medications: hives,
________________________
________________________________________________________________
skin rash, breathing
________________________
________________________________________________________________
problems or other?
Are there medications, other than those you are allergic to, you would prefer not to take due to unpleasant side effects?
Yes
No
If Yes, please specify which medication and what the unpleasant side-effect was:
CHEMICAL USE
Chemical use most recent 12 months (client self-report)
Most Recent Pattern of use and
Date of last
Withdrawal
Method of
Primary Drug Use
Age of
Duration
use and time,
Potential?
use
First Use
How much you use, how often, and do
Needs special
if needed
(oral, smoked,
(Check your drug of choice)
you need more or less to get the same
care?
snort, IV, etc)
effect?
ALCOHOL
CAFFEINE
MARIJUANA/
HASHISH
COCAINE/CRACK
METH/
AMPHETAMINES
HEROIN
SYNTHETICS
INHALANTS
BENZODIAZEPINES
HALLUCINOGENS
BARBITURATES/
SEDATIVES/
HYPNOTICS
OVER-THE-
COUNTER DRUGS
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Parent category: Medical