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Substance Use
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Consider a typical week during the past month. Please fill in a number for each day of the week indicating the typical number of
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drinks you usually consume on that day and the typical number of hours you usually drink on that day.
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1 drink = 12 oz. beer
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1 drink = 4 oz. wine
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1 drink = 1 oz. hard alcohol (regular shot glass)
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Monday
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Number of Drinks
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Number of Hours
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Tuesday
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Number of Drinks
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Number of Hours
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Tuesday
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Number of Drinks
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Number of Hours
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Wednesday
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Number of Drinks
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Number of Hours
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Thursday
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Number of Drinks
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Number of Hours
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Friday
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Number of Drinks
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Number of Drinks
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Saturday
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Number of Drinks
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Number of Hours
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Sunday
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Number of Drinks
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Number of Hours
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In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day?
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How many caffeinated beverages do you drink per day?
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Coffee
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Soda
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Tea
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Have you ever been treated for alcohol or drug use or abuse?
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If yes, for which substances
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Have people annoyed you by criticizing you’re drinking or drug use?
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Have you ever felt you ought to cut down on your drinking or drug use?
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Have you ever felt bad or guilty about your drinking or drug use?
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Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?
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Do you think you may have a problem with alcohol or drug use?
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If yes, which ones?
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Have you ever abused prescription medication?
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If yes, which ones and for how long?
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Have you ever smoked cigarettes?
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If yes, how many packs per day on average?
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How many years?
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If you smoked in the past, how many years did you smoke and when did you quit?
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E-Cigarettes?
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Pipe, cigars, or chewing tobacco?
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How often per day on average?
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How many years?
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If you used any of these products in the past how many years did you use and when did you quit?
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Exercise Level
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Do you exercise?
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How often?
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Aerobic (physical exercise of low to high intensity)?
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Anaerobic (weight lifting)?
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Athletic Activities (team sports, golf, tennis, and skiing etc.)?
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Occupational Level
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Current Employment Status
• • •
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How long in present position?
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Where do you work?
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What is/was your occupation?
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Have you ever served in the military?
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If yes, which branch and when?
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Any DHS/ Protective Services Interventions?
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If yes, date and cause?
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Depositions
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Legal History
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Have you ever been arrested?
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Do you have any pending legal problems?
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Are you a convicted felon?
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Are you a registered sex offender?
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Spiritual Life
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How long have you regularly attended Crossings?
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Please indicate activities in which you are involved?
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Please explain
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What other ministry opportunities do you participate in at Crossings?
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If yes, what is the level of your involvement?
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Do you find your involvement helpful during this time, or doesthe involvement make things more difficult or stressful for you?
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Describe if possible
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Describe your personal spiritual practices
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Is there anything else about your life that you would like us to know?
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Signature
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Date
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