DATE:
Time with patient (min):
Performed by:
Primary Physician:

SCREENING:
Circle each substance used and record Substance Involvement Score

Substance List:
a. tobacco ______
b. alcohol _______
c. cannabis ______
d. cocaine _______
e. prescription amphetamines ___
f. methamphetamine ______
g. inhalants ______
h. sedatives ______
i. hallucinogens ______
j. street opioids ______
k. prescription opioids ______
l. other ______

IF ALCOHOL USE (circle below):
How many times in the past year have you had:
 

Past 3 months (list substances):_______________

Biological Test Results:_______________

PLAN:

Discussed screening results with patient (check if completed)______

Provided a Brief Intervention  (check if completed)______

How ready is patient to change behavior?  
Unwilling_____  Tentative______ Ready_______

Change Plan completed? Yes ____ (attach)   No ____  N/A____

Change Plan appointment?        Yes ____  No___  N/A____

REFERRAL STATUS:  

Refer for further assessment?__________ Refused?____________  N/A _______

Refer to detox? _________Refused?___________   N/A_______

FOLLOW-UP PLANS:

Date of next appointment to check progress______

Or for low-risk patients, re-screen on next RTC________, or one year (if negative). 
      

Provider Signature:________________________

Patient Signature:_____________________