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Are you allergic to any type of medication?
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Do you have any allergies to foods, insect bites, plants, animals, etc?
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How many days have you experienced medical problems in the past 30 days?
Comments:
ALCOHOL / DRUG HISTORY:
(A) Begin with your substance of choice
(B) Secondary
substance of choice
(A) Substance Used:
(A) Date First Used:
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(A) Frequency Used:
(A) Amount:
(A) Date Last Used:
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Date
(B) Substance Used:
(B) Date First Used:
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(B) Frequency Used:
(B) Amount:
(B) Date Last Used:
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Withdrawal Symptoms
PREVIOUS MAT/SUB TREATMENT
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