The Substance Abuse Screening Form Template by WPForms is a great solution for counselors, healthcare providers, and rehabilitation centers that are looking for an effective way to assess substance abuse disorders.
How Does the Substance Abuse Screening Form Template Work?
The Substance Abuse Screening Form Template requires the WPForms Pro License and the Survey and Polls Addon to accurately record information and plot the results into graphs, charts, and more. Fields include:
- Personal Information:
- Full Name: Records the name of the individual filling out the form.
- Gender: Helps in understanding gender-specific patterns in substance abuse.
- Date of Birth: Age is a crucial factor in assessing substance use behaviors.
- Email: A vital contact detail for sending follow-up information or resources.
- Phone: Enables direct communication for urgent consultations or feedback.
- General Health:
- Current Health Status: A general overview of the individual’s current physical and mental health.
- Known Health Conditions: Identifies existing medical conditions that may influence substance use.
- Current Medications: Important for assessing potential interactions with substances and broader health context.
- Substance Use History:
- History of Alcohol Use: Gathers information about alcohol consumption patterns and duration.
- History of Recreational Drug Use: Assesses the extent and nature of any non-medical drug use.
- History of Prescription Drug Misuse: Important for understanding misuse of prescribed medications.
- Behavioral Assessment:
- Impact of Substance Use on Daily Life: Evaluates how substance use affects personal, professional, and social life.
- Previous Attempts to Quit or Reduce Use: Sheds light on the individual’s treatment history and motivation levels.
- Experienced Withdrawal Symptoms: Helps in understanding the potential need for medical assistance during withdrawal.
Sign up with WPForms today and access the Substance Abuse Screening Form Template. It is an important tool for people who work in drug abuse treatment because it gives them the data they need to make smart choices and provide personalized help.
