Chemical use survey

In order to treat you effectively, I need information about the ways you and your family have used alcohol, drugs, and/ or other chemicals that can affect you psychologically. So please answer these questions fully.

Your initials
Date of birth

A. What have you used?

1. Think about any and all chemicals you have used, and indicate how much you used (amount) and how often. Then indicate all the effects it had on you (mental, physical, family, legal, etc.).

2. Which is your primary drug of choice?
3. For each chemical you currently use, what causes you to stop? Enter one or more of these letters in the last column above: A = The money runs out. B = I use up my supply. C = Personal choice. D = Unconsciousness. E = Achieved my purpose. F = Other reasons:
4. What are or were your sources of money for buying the chemicals you have used?
B. Which of these have you had?
Explain any other problems you have had

C. Family patterns of chemical use

Please describe the chemical(s) used by family members.
Please add any other information you think is important:
D. Treatment for chemical use

*In the fourth column, use these codes: AA/NA = Alcoholics Anonymous/Narcotics Anonymous; O = Outpatient counselling; ID = Inpatient detoxification; IT = Inpatient treatment (e.g., 28-day); O = Other.

**In the last column, use these codes: W = made situation Worse; N = No change; U = better Understanding of addiction; R = Reduction of use; BA = Brief abstinence (up to a month); LA = Long-term abstinence (several months or more); O = Other effects:

F. Self-description of use

Would you say you
Or how would you describe your use
Would you say you
Or how would you describe your use?