Substance Use Disorder Nursing Assessment Form

Substance Use Disorder Nursing Assessment Form
Use this form to document a comprehensive nursing assessment for substance use disorder, including substance use history, withdrawal symptoms, treatment history, supports, and current clinical observations.
Patient Identification and Assessment Context
Patient Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sex/Gender
Assessment Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Assessor / Nurse Name
First NameMiddle NameLast Name
Referral Source
Setting / Location of Assessment
Other
Reason for Assessment
Substance Use History
Primary substance(s) used
Other
Secondary substances used
Other
Route of use
Other
Frequency of use
Quantity or pattern of use
Age at first use
Last use date/time
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Duration of use
Triggers for use
Other
Periods of abstinence
Prior overdose and withdrawal history
Rows Yes No
Prior overdose history
History of withdrawal symptoms
Withdrawal, Physical, and Mental Health Assessment
Current withdrawal symptoms
Other
Severity of cravings
Symptom severity

1
2
3
4
5
6
7
8
9
10
1 is Mild, 10 is Severe
Sleep and appetite changes
Other
Pain or discomfort
Other
Physical symptoms noted
Other
Mental health symptoms
Rows Absent Mild Moderate Severe
Mood changes
Anxiety
Depressive symptoms
Hallucinations
Paranoia
Safety concerns
Other
Acute medical red flags
Other
Notable observations
Treatment History and Current Supports
Previous detox received?
Prior treatment types
Other
Medication-assisted treatment details
Relapse history details
Current prescribed medications
Allergies or medication reactions relevant to care
Primary care provider name
Behavioral health provider or program
Support system and family involvement
Readiness for treatment

1
2
3
4
5
6
7
8
9
10
1 is Not ready, 10 is Fully ready
Nursing Observations, Risk Screen, and Consent Acknowledgment
General appearance and behavior
Orientation
Communication
Affect
Immediate safety concerns
Other
Should be Empty:

Select theme:

Rows	Absent	Mild	Moderate	Severe
Mood changes
Anxiety
Depressive symptoms
Hallucinations
Paranoia

Rows	Yes	No
Prior overdose history
History of withdrawal symptoms

Substance Use Disorder Nursing Assessment Form

Patient Identification and Assessment Context

Substance Use History

Withdrawal, Physical, and Mental Health Assessment

Treatment History and Current Supports

Nursing Observations, Risk Screen, and Consent Acknowledgment