Substance Influence Assessment
Use this form to document observations and context when assessing possible substance influence.
Full Name of Individual Being Assessed
*
First Name
Last Name
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Assessment
*
Observed Behaviors or Symptoms (select all that apply)
*
Slurred speech
Unsteady gait
Red or watery eyes
Odor of substances
Confusion or disorientation
Aggressive or unusual behavior
Other
Suspected Substance(s)
*
Alcohol
Cannabis
Prescription medication
Illicit drugs
Unknown
Other
Physical Indicators (select all that apply)
Dilated or constricted pupils
Tremors
Sweating or chills
Pale or flushed skin
Rapid or slow pulse
Other
Additional Notes or Comments
Name of Assessor
*
Submit Assessment
Should be Empty: