Drug and Alcohol Risk Assessment Questionnaire Form
Complete this questionnaire to help assess drug and alcohol-related risk and related impact patterns. Please answer the questions as accurately as possible.
Participant Information
Full Name
*
First Name
Middle Name
Last Name
Age
*
Email Address
*
example@example.com
Substance Use Screening
Alcohol use frequency
*
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Drug use frequency
*
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Substances used in the past 30 days
Alcohol
Cannabis (marijuana)
Prescription opioids not as prescribed
Non-prescribed stimulants
Sedatives or tranquilizers
Cocaine
Methamphetamine
Hallucinogens
Inhalants
Other
Risk and Impact Assessment
Rate the frequency or severity of the following risk indicators
*
Rows
Never
Rarely
Sometimes
Often
Severe
Cravings or urges
1
2
3
4
5
Loss of control over use
6
7
8
9
10
Blackouts or memory gaps
11
12
13
14
15
Missed responsibilities
16
17
18
19
20
Safety concerns
21
22
23
24
25
Has substance use affected your work, school, or relationships?
*
No
Yes, occasionally
Yes, sometimes
Yes, frequently
How ready are you to change your substance use or seek support?
*
Not ready
Thinking about it
Somewhat ready
Ready soon
Very ready
Submit Questionnaire
Should be Empty: