Primary Care Substance Misuse Screening Template
Patient Name
Date of Birth
Date of Assessment
Substances Used (select all that apply)
Alcohol
Tobacco
Cannabis
Opioids
Cocaine
Benzodiazepines
Other
Frequency of Use
Daily
Weekly
Monthly
Occasional
Rarely
Duration of Use
Adverse Consequences
Previous Treatments
Willingness to Change
Yes
No
Not Sure
Notes / Additional Information