Substance Abuse Screening for Older Adults
Patient Information
Full Name
Date of Birth
Age
Screening Questions
1. In the past year, have you used alcohol, prescription medications, or other substances more than intended?
Yes
No
2. Have you experienced any problems related to your substance use (health, relationships, legal, financial)?
Yes
No
3. Have others expressed concern about your use of alcohol or other substances?
Yes
No
4. Have you ever tried and failed to cut down or stop using a substance?
Yes
No
Additional Comments / Notes