Elderly Substance Abuse Screening Questionnaire
Name
Date of Birth
Gender
Female
Male
Other
1. Do you consume alcohol?
Never
Occasionally
Regularly
Daily
2. Do you use prescription medications not as directed?
Never
Rarely
Sometimes
Frequently
3. Have you used any illicit drugs in the past year?
Yes
No
4. Has a family member or friend expressed concern about your substance use?
Yes
No
5. Have you experienced memory loss or confusion after using substances?
Never
Rarely
Sometimes
Often
6. Do you take more of a substance than intended?
Never
Rarely
Sometimes
Often
7. Have you tried to cut down or stop using substances, but couldn't?
Yes
No
Additional Comments