Pregnancy Substance Use Screening Form
Please complete the Pregnancy Substance Use Screening Form to help us understand your needs. All questions are relevant to pregnancy and substance use screening only.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Estimated Due Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently pregnant?
*
Yes
No
In the past 3 months, have you used any tobacco or nicotine products (including cigarettes, vaping, or smokeless tobacco)?
*
Yes
No
In the past 3 months, have you consumed any alcohol?
*
Yes
No
In the past 3 months, have you used any prescription medications not prescribed to you?
*
Yes
No
In the past 3 months, have you used any recreational drugs (such as marijuana, cocaine, heroin, methamphetamines, etc.)?
*
Yes
No
Is there anything else you would like to share regarding substance use during your pregnancy?
Submit
Should be Empty: