Brief Health Screen "*" indicates required fields We ask all our adult patients about substance use and mood because these factors can affect your health. Please ask your doctor if you have any questions. Your answers on this form will remain confidential.Patient Name* First Last Date of Birth* MM slash DD slash YYYY Email* AlcoholOne drink = 12 oz beer | 5 oz wine | 1.5 oz liquor (one shot)What is your gender?* Men Women How many times in the past year have you had 5 or more drinks in a day?* None 1 or more How many times in the past year have you had 4 or more drinks in a day?* None 1 or more DrugsRecreational drugs include methamphetamines (speed, crystal) cannabis (marijuana, pot), inhalants (paint thinner, aerosol, glue), tranquilizers (Valium), barbiturates, cocaine, ecstasy, hallucinogens (LSD, mushrooms), or narcotics (heroin).How many times in the past year have you used a recreational drug or used a prescription medication for non-medical reasons?* None 1 or more MoodDuring the past two weeks, have you been bothered by little interest or pleasure in doing things?* No Yes During the past two weeks, have you been bothered by feeling down, depressed, or hopeless?* No Yes CommentsThis field is for validation purposes and should be left unchanged. Δ Back to Annual Physical Visit
