Custody Evaluation Questionnaire Template Page 21
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2721
_________________________________________________________________
_________________________________________________________________
List all psychiatric and pain medications you are currently taking:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
List all psychiatric and pain medications you have ever taken:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Alcohol/Drug Use. (If you have been in a drug or alcohol treatment
program, please provide the hospital or clinic records)
Have you ever experimented with or used the following
substances:
YES
NO
a)
Alcohol, more than 8 drinks in a day
____
____
b)
Marijuana or cannabis in other forms
____
____
c)
Cocaine
____
____
d)
Amphetamines/Methamphetamines
____
____
e)
Barbiturates
____
____
f)
Hallucinogens
____
____
g)
Heroin
____
____
h)
Ecstasy
____
____
i)
Other_________________________
____
____
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Parent category: Legal