Patient/Client Name: __________________________ Patient/Client DOB: _____________________

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Instructions: Ask your patient each question, then mark answers affirmative when appropriate (the default setting is a negative response). At the end of the survey, the screening tool will tally the responses to generate a substance involvement score, determine risk and recommended level of intervention, and provide additional resources.

NM Assist

Clinician’s Screening Tool for Drug Use in General Medical Settings*

Quick Screen
Quick Screen Quick Result Question 1 of 8 Question 2 of 8 Question 3 of 8 Question 4 of 8 Question 5 of 8 Question 6 of 8 Question 7 of 8 Question 8 of 8 Question 8 of 8

In the past year, how many times have you used the following?
Drug Type NeverOnce or TwiceMonthlyWeeklyDaily or Almost Daily
Alcohol
For , 5 or more drinks in a day
Tobacco products
Prescription Drugs for Nonmedical Reasons
Illegal drugs
Give Feedback



*This screening tool was adapted from Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., Saitz, R. (2010). A Single-Question Screening Test for Drug Use in Primary Care. Arch Intern Med. 170(13):1155-1160. doi:10.1001/archinternmed.2010.140.

Note: This website collects no personally identifiable information and does not store your responses to any of the following questions.