My Substance Use Record

Name:

DOB:

No drug or substance use.

List any and all drug (s) that you have ever taken:

E.g., , Amphetamines*, Anxiolytics*, Hypnotics*, Inhalants*, Opioids*, Oxycontin*, Sedative:

CURRENT SUBSTANCE-1:

Type of Drugs(1)

Age of First Us(1)

Date of last use(1)

Route(1)

Quantity(1)

On average, how much do you take on each day that you take them?

Cost(1)

How Much do you spend a day on drugs

Periods of abstinence(1)

Frequency of Substances used

CURRENT SUBSTANCE-2:

Type of Drugs(2)

Age of First Us(2)

Date of last use (2)

Route(2)

Quantity(2)

On average, how much do you take on each day that you take them?

Cost(2)

How Much do you spend a day on drugs

Periods of abstinence (2)

Frequency of Substances used(2)

CURRENT SUBSTANCE-3:

Type of Drugs(3)

Age of First Us (3)

Date of last use (3)

Route(3)

Quantity(3)

On average, how much do you take on each day that you take them?

Cost(3)

How Much do you spend a day on drugs

Periods of abstinence (3)

Frequency of Substances used (3)

CURRENT SUBSTANCE-4:

Type of Drugs(4)

Age of First Us (4)

Date of last use (4)

Route(4)

Quantity(4)

On average, how much do you take on each day that you take them?

Cost(4)

How Much do you spend a day on drugs

Periods of abstinence (4)

Frequency of Substances used (4)

CURRENT SUBSTANCE-5:

Type of Drugs(5)

Age of First Us (5)

Date of last use (5)

Route(5)

Quantity(5)

On average, how much do you take on each day that you take them?

Cost(5)

How Much do you spend a day on drugs

Periods of abstinence (5)

Frequency of Substances used (5)

Others Substances used:

History of other addictive disorders:

Do you have history of other addictive disorders? (e.g. gambling, sex, etc)

(Please Initial, If NO current or past history of substance use)