ICU Admission Substance Use History Form
Patient Information
Patient Name:
Medical Record Number:
Date of Admission:
Substance Use History
Tobacco Use:
Current
Former
Never
Packs/Day:
Years Tobacco Used:
Alcohol Use:
Current
Former
Never
Drinks/Day:
Years Alcohol Used:
Illicit Drug Use:
Current
Former
Never
Type(s) of Drug(s):
Years Drug Used:
Other Relevant History
Substance Withdrawal History:
Comments / Other: