Rural Community Substance Use Screening Form
Full Name
Date of Birth
Address
Contact Number
Substance Use History
Have you used any of the following substances in the past year? (Check all that apply)
Alcohol
Tobacco
Marijuana
Prescription drugs (misused)
Methamphetamine
Opioids
Other
If 'Other', please specify
How often do you use these substances?
Daily
Weekly
Monthly
Rarely
Never
Have you ever tried to reduce or stop using these substances?
Yes
No
Are you concerned about your substance use?
Yes
No
Unsure
Additional Information
Does your family have a history of substance use issues?
Yes
No
Unsure
Any health problems related to substance use?
Additional Comments