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Drug and Alcohol
Drugs and Alcohol usage:
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
Do you use alcohol?
Never
Currently
No Longer
Do you abuse alcohol?
Never
Currently
No Longer
Have you had alcohol related health problems?
Never
Currently
No Longer
Have you had alcohol related problems? (marital, violence, missed work, relationships)
Never
Currently
No Longer
Do any of your children have alcohol related problems?
Never
Currently
No Longer
Do you use drugs?
Never
Currently
No Longer
Do you abuse drugs?
Never
Currently
No Longer
Which drugs have you or do you use?
Stimulants:
Never
Currently
No Longer
Which one?
Opioids:
Never
Currently
No Longer
Which one?
Depressants:
Never
Currently
No Longer
Which one?
Barbiturates:
Never
Currently
No Longer
Which one?
Benzodiazepines:
Never
Currently
No Longer
Which one?
Hallucinogens:
Never
Currently
No Longer
Which one?
Dissociates:
Never
Currently
No Longer
Which one?
Inhalants:
Never
Currently
No Longer
Which one?
Cannabinoids:
Never
Currently
No Longer
Which one?
Steroids:
Never
Currently
No Longer
Which one?
Submit
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