Client Health Questionnaire

Administer a set of brief clinical screening questionnaires covering mood symptoms, alcohol use, and substance use in a single intake session.

Use this template

Page 1

Name

Nombre

Apellido

Date

Name

Nombre

Apellido

Date

Name

Nombre

Apellido

Date

Have you ever been in treatment for an alcohol problem?

Yes No

Name

Nombre

Apellido

Date

The following questions refer to drug use within the past 12 months.

Have you used any of the following drugs (prescription and/or recreational) in the past year?

Yes No

If you answered yes to the question above, please check all that apply.

Marijuana Cocaine Opioids or prescription painkillers Stimulants Sedatives or tranquilizers Other

How often have you used these drugs?

Daily Weekly Monthly Rarely

Have you ever injected drugs?

Yes No

Have you ever been in treatment for substance abuse?

Yes No

Thank you for completing this questionnaire. Your information is confidential.

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