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Scott M. Yarosh, MD
Amity Carlson, PA-C, MS
Courtney Schneider, PA-C
Dawn Daniels-Bohnen, Clinic Manager
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Substance Use Form
Alcohol
Current Use
Past Use
Never Used
Date of last use (if applicable)
If current use, how many drinks per week?
Medical Marijuana
Current Use
Past Use
Never Used
Date of last use (if applicable)
If current use, how often per week
Drugs (marijuana, heroin, cocaine, meth, etc.)
Current Use
Past Use
Never Used
Date of last use (if applicable)
List drug names and frequency of use:
Opiates (Hydrocodone, Oxycodone, OxyContin, Morphine, etc.)
Current Use
Past Use
Never Used
Date of last use (if applicable)
List opiate names and frequency of use:
Tobacco
Current Use
Past Use
Never Used
Date of last use (if applicable)
Substance use treatment (facility name & date):
Please list any family members with mental health issues and their diagnosis:
Family members with chemical dependency issues:
Choose an option
Please state if alcohol or drugs, or both
(if more) Family members with chemical dependency issues:
Choose an option
Please state if alcohol or drugs, or both
Submit
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