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Where did you find us?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Which specialists do you see?
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Primary Care Physician
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Substance abuse screening
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Do you use substances in moderation?
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Have you lost friends because of using?
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have you ever experienced blackouts?
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Has using lead to difficulty at work?
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Difficult to stop drinking after 1-2 drinks?
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Have you avoided obligations when using?
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Family express concern about your using?
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Have you avoided family because of using?
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Friends express concern about your using?
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Have you avoided kids because of using?
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Do you ever feel guilty about using?
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Have you missed work because of using?
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Have you attended AA or NA?
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Do you use before noon?
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Have you ever got in fights when using?
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Have you experience shaking after using?
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Has using ever lead to relationship problems?
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Have you ever been hospitalized after using?
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Have you ever been told you have liver trouble?
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Has use resulted in psychiatric hospitalization?
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Have you ever got professional help for using?
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Have you ever gotten a DUI?
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Have you ever got religious help for using?
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Have you ever been arrested because of using?
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Any antidepressants?
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Irritability or dramatic changes in behavior?
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Has using been a problem before?
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Comments
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Recommendations
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Completed by:
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