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Resource Guide: Screening for Drug Use in General Medical Settings

Sample Progress Notes

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

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:

For men: 5 or more drinks in a day? For women: 4 or more drinks in a day?


Past 3 months (list substances): __________

Biological Test Results: __________

Level of risk associated with different Substance Involvement Score ranges for illicit or nonmedical prescription drug use.
0-3 Low Risk
4-26 Moderate Risk
27+ High Risk


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 _____


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

Refer to detox? __________  Refused? __________  N/A __________


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: _________________________

This page was last updated March 2012

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Cite this article

NIDA. (2012, March 1). Resource Guide: Screening for Drug Use in General Medical Settings. Retrieved from https://www.drugabuse.gov/publications/resource-guide-screening-drug-use-in-general-medical-settings

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