Substance Use Screening Form

Substance Use Screening Form — Form Fields

This healthcare template includes 7 fields. Confidential screening tool to assess alcohol, tobacco, and drug use as part of routine primary care or behavioral health intake. Supports early intervention referrals. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Do you currently use tobacco products? (multiple choice, required) — options: No, never, Former user, Yes — cigarettes, Yes — e-cigarettes/vaping, Yes — other tobacco
• How often do you drink alcohol? (multiple choice, required) — options: Never, Monthly or less, 2–4 times per month, 2–3 times per week, 4 or more times per week
• In the past year, have you used recreational drugs or used prescription drugs in a way not prescribed? (multiple choice, required) — options: No, Yes
• Have you ever felt you should cut down on your drinking or drug use? (multiple choice, optional) — options: Yes, No
• Are you interested in information or support for reducing substance use? (multiple choice, optional) — options: Yes, No, Maybe
• Additional Comments (long text, optional)