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

SCREENING:
Circle each substance used and record Substance Involvement Score

Substance List:
a. cannabis __________
b. cocaine __________
c. prescription amphetamines __________
d. street opioids __________
e. methamphetamine __________
f. inhalants __________
g. sedatives __________
h. prescription opioids __________
i. hallucinogens __________
j. 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, rescreen on next RTC __________, or one year (if negative). 
      

Provider Signature: _________________________

Patient Signature: _________________________