The Drug Use Assessment Form Template by WPForms is an excellent tool designed for counselors, healthcare professionals, and rehabilitation centers to help evaluate individuals for drug use disorders effectively.
How Does the Drug Use Assessment Form Template Work?
This template utilizes the WPForms Pro License alongside the Survey and Polls Addon, which allows for a detailed collection of data that can be visualized in graphs and charts for better understanding and analysis. Fields include:
- Personal Information:
- Full Name: Collects the full name of the person completing the form.
- Gender: Provides insights into gender-specific patterns of drug use.
- Date of Birth: Helps assess age-related drug use behaviors.
- Email: A critical means of contacting the individual for further support.
- Phone: Facilitates direct and immediate communication if necessary.
- General Health:
- Current Health Status: Offers an overview of the person’s current physical and mental health.
- Known Health Conditions: Identifies any existing health issues that might impact drug use.
- Current Medications: Crucial for understanding possible drug interactions and overall health conditions.
- Substance Use History:
- History of Alcohol Use: Details about the individual’s alcohol consumption habits and history.
- History of Recreational Drug Use: Looks at the use of non-prescription drugs for non-medical reasons.
- History of Prescription Drug Misuse: For gauging misuse of medications prescribed initially for legitimate medical reasons.
- Behavioral Assessment:
- Impact of Drug Use on Daily Life: Assesses how drug use affects the individual’s day-to-day life across personal, professional, and social areas.
- Previous Attempts to Quit or Reduce Use: Offers insight into past efforts to manage or stop drug use, highlighting motivation and treatment history.
- Experienced Withdrawal Symptoms: Essential for determining the need for medical support during cessation.
Sign up with WPForms today and access the Drug Use Assessment Form Template, which delivers critical insights needed to make informed decisions and offer tailored support, enhancing the chances of successful recovery outcomes.
