My Substance Use Record

Name:

DOB:

List What drugs have you ever taken? Within your life, list the types of drugs have you 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)

No drug or substance use.