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: _________________________