Nutrition Meal How often ? Typical foods eaten Typical Amount eaten (times per (please circle) week) Breakfast Low Medium High Lunch Low Medium High Dinner Low Medium High Snacks Low Medium High Comments: Chemical Use History Method of Age of Used within Freq. of Age of Used within the use and last the last 30 use first use last 48 hours? amount use days? Yes No Yes No Alcohol Barbiturates Valium/Librium Cocaine/Crack Heroin/Opiates Marijuana PCP/LSD/Mesc. Inhalants Caffeine Nicotine Over the counter Presc. Drugs Other drugs Substance(s) of preference 1. 3. 2. 4. Substance Abuse Questions Describe when and where you typically use substances: Describe any changes in your use patterns: Describe how your use has affected your family or friends (include their perceptions of your use): Reason(s) for use: Addicted Build confidence Escape Self-medication
Nutrition Meal How often ? (times per week) Typical foods eaten Typical Amount eaten (please circle) Breakfast Low Medium High Lunch Low Medium High Dinner Low Medium High Snacks Low Medium High Comments: Chemical Use History Method of use and amount Freq. of use Age of first use Age of last use Used within the last 48 hours? Used within the last 30 days? Yes No Yes No Alcohol Barbiturates Valium/Librium Cocaine/Crack Heroin/Opiates Marijuana PCP/LSD/Mesc. Inhalants Caffeine Nicotine Over the counter Presc. Drugs Other drugs Substance(s) of preference 1. 3. 2. 4. Substance Abuse Questions Describe when and where you typically use substances: Describe any changes in your use patterns: Describe how your use has affected your family or friends (include their perceptions of your use): Reason(s) for use: Addicted Build confidence Escape Self-medication
Adult-History-Questionnaire.docx