Chemical Dependency - Assessment/screening Form Page 3

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Date ____________________________
Name, Soc Sec #, Client ID, DOB
ALCOHOL AND DRUG USE HISTORY
Age
Age
Date
Pattern/Amount/
st
Specific
1
regular
last
Method
Substance
How Often of used
Substance
use
use
used
of use
Alcohol
(Beer, Liquor,
Wine)
Cannabis
(Marijuana,
Hashish)
Nicotine
(Cigarettes,
Chewing Tobacco, Snuff,
Cigars)
Cocaine
(Powder, Crack, IV)
Stimulants
(amphetamines,
speed, crank, crystal,
mini-thins, diet pills)
Hallucinogens
(LSD,
PCP/angel dust, Peyote,
Mushrooms, Ecstasy)
Opiates/Narcotics
(Dilaudid, Morphine, Darvon,
OxyContin, Percodan,
Percocet, Demerol, Codeine,
Loritab, Heroin, Methadone,
Vicodin, etc.)
Tranquilizes
(Valium, Xanax, Librium,
Ativan, Klonopin, etc.)
Sedatives, Sleeping Pills
Steroids
Inhalants
Prescription Medications
Other
G:\COMMON\forms\Screening – Eval.doc
Rev. 07/27/10 clp

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