Substance Use Screening Form - Alternative

Substance Use Screening Form - Alternative — Form Fields

This healthcare template includes 7 fields. Confidential screening tool to assess alcohol, tobacco, and drug use patterns for clinical review. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• How often do you have a drink containing alcohol? (dropdown selection, required) — options: Never, Monthly or less, 2–4 times per month, 2–3 times per week, 4 or more times per week
• Do you currently use tobacco products? (multiple choice, required) — options: Yes, daily, Yes, occasionally, No, but I used to, Never
• Have you used any of the following in the past 12 months? (select all that apply) (checkboxes, optional) — options: Cannabis / Marijuana, Prescription opioids (not as prescribed), Stimulants (cocaine, methamphetamine), Sedatives or tranquilizers, None of the above
• Have you ever felt you should cut down on your substance use? (multiple choice, required) — options: Yes, No
• Are you currently in any treatment or recovery program? (multiple choice, required) — options: Yes, No
• Additional notes or context you would like to share (long text, optional)