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Drug History
What Is The Primary Drug of Abuse?
Alcohol
Cocaine
Crack
Heroin
Methamphetamine
Ecstasy
GHB
Inhalants
Ketamine
LSD
Marijuana
Methadone
PCP
Prescription Drugs
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What Is The Secondary Drug of Abuse?
Alcohol
Cocaine
Crack
Heroin
Methamphetamine
Ecstasy
GHB
Inhalants
Ketamine
LSD
Marijuana
Methadone
PCP
Prescription Drugs
Other
At What Age Did The User First Take Drugs?
How Old Is The User Now?
What Are The Resulting Problems of The User's Addiction?
What Is The Family's Attitude Toward The User's Addiction?
Does The User Admit To Having A Problem?
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no
Does The User Want Help ?
yes
no
Medical History
Does The User Have Any Known Mental Health Conditions?
No
Yes
If So, Please List The Condition(s) And Any Necessary Details:
Does The User Have Medical Insurance?
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Yes
Does The User Have Legal Issues?
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Yes
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