Prenatal Substance Exposure Interview
Pregnancy & Maternal Information
Mother's Name
Date of Interview
Mother's Date of Birth
Number of Pregnancies
Weeks Pregnant when Substance Use Began
Substance Use During Pregnancy
Substances Used (select all that apply)
Tobacco/Nicotine
Alcohol
Marijuana/THC
Opioids
Cocaine
Methamphetamine
Prescription Drugs (non-prescribed)
Other
If "Other", please specify
Frequency and Amount of Use
Screening & Testing
Were any screenings or tests conducted? If yes, what type and when?
Results of screenings/tests
Additional Information
Any known medical complications during pregnancy?
Additional notes or comments