Pediatric Substance Exposure Screening
Patient Name
Date of Birth
Date of Screening
Provider
Substance Exposure History
Known prenatal substance exposure?
Yes
No
Unknown
If yes, indicate substance(s) (select all that apply)
Alcohol
Tobacco
Marijuana
Opioids
Stimulants
Other
If other, specify:
Any current exposure to substances in environment?
Yes
No
Unknown
If yes, indicate substance(s) (select all that apply)
Alcohol
Tobacco
Marijuana
Opioids
Stimulants
Other
If other, specify:
Additional Notes