Substance Abuse Screening Form

Substance Abuse Screening Form — Form Fields

This healthcare template includes 8 fields. Conducts a confidential screening for substance use disorders to guide treatment planning. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Substances used in the past 12 months (check all that apply) (checkboxes, optional) — options: Alcohol, Cannabis, Prescription opioids (non-prescribed), Stimulants (cocaine, methamphetamine), Sedatives / benzodiazepines, Tobacco / nicotine, Other
• How often do you use alcohol or other substances? (dropdown selection, required) — options: Never, Monthly or less, Weekly, Daily or almost daily
• Have substance use problems caused difficulties in your life? (multiple choice, required) — options: Yes, No
• Have you ever received treatment for substance use? (multiple choice, required) — options: Yes, No
• Are you interested in receiving support or treatment? (multiple choice, required) — options: Yes, Maybe, No
• Additional information you would like to share (confidential) (long text, optional)