Prenatal Substance Abuse Screening Form
Patient Information
Name
Date of Birth
Last Menstrual Period
Estimated Date of Confinement (EDC)
Provider Name
Screening Date
Substance Use History
Tobacco Use
Yes
No
Details
Alcohol Use
Yes
No
Details
Illicit Drug Use
Yes
No
Details
Prescription Drug Use (non-prescribed or misuse)
Yes
No
Details
Other Substance Use
Risk Assessment
Prior history of substance abuse?
Yes
No
Partner or household member with substance abuse history?
Yes
No
Provider Concerns / Additional Notes