Substance Use Do you currently use? Past Use Amount Frequency Age of Initiation Caffeine Nicotine Alcohol Marijuana Opioids Amphetamines Hallucinogenic Prescription Medication Over the counter medication Describe: History of legal charges related to substance use? Yes No ☐ ☐ Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Describe: Behavioral Observations Activity Diminished Normal Excessive Unusual ☐ Frozen Purposeful Restless ☐ ☐ ☐ Catatonic Coordinated Squirming ☐ ☐ ☐ Other ☐ Almost motionless Fidgety ☐ ☐ Little animation Constant movement ☐ ☐ Psychomotor ☐ Hyperactive ☐ retardation Slowed reaction Other ☐ ☐ time Other ☐ Speech Slowed Normal Pressured Verbose Unusual Minimal response Initiates Excessively wordy Over productive ☐ ☐ ☐ ☐ ☐ Unspontaneous Alert/responsive Expansive winded ☐ ☐ ☐ ☐Long Sluggish Productive Rapid stop ☐ ☐ ☐ ☐Non Paucity Animated Fast Frequent run ons ☐ ☐ ☐ ☐ Impoverished Spontaneous Rushed of ☐ ☐ ☐ ☐Flight Single word ☐ Other verbal ☐Smooth ☐ answers Other Other ☐ ☐ ☐Other
Substance Use Do you currently use? Past Use Amount Frequency Age of Initiation Caffeine Nicotine Alcohol Marijuana Opioids Amphetamines Hallucinogenic Prescription Medication Over the counter medication History of legal charges related to substance use? ☐ Yes ☐ No Describe: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Describe: Behavioral Observations Activity Diminished Normal Excessive Unusual ☐ Frozen ☐ Purposeful ☐ Restless ☐ ☐ Catatonic ☐ Coordinated ☐ Squirming ☐ Almost motionless ☐ Other ☐ Fidgety ☐ Little animation ☐ Constant movement ☐ Psychomotor retardation ☐ Hyperactive ☐ Slowed reaction time ☐ Other ☐ Other Speech Slowed Normal Pressured Verbose Unusual ☐ Minimal response ☐ Initiates ☐ Excessively wordy ☐ Over productive ☐ ☐ Unspontaneous ☐ Alert/responsive ☐ Expansive ☐Long winded ☐ Sluggish ☐ Productive ☐ Rapid ☐Non stop ☐ Paucity ☐ Animated ☐ Fast ☐ Frequent run ons ☐ Impoverished ☐ Spontaneous ☐ Rushed ☐Flight of ☐ Single word answers ☐Smooth ☐ Other verbal ☐ Other ☐ Other ☐Other
revised-2016-Youth-Pre-Evaluation-Screening-form.docx