Chemical History Use Form Name(Required) First Last Email(Required) Enter Email Confirm Email Phone(Required)Today's Date(Required) MM slash DD slash YYYY Chemical Type(Required) Alcohol (Beer, Wine, Liquor) Cocaine/Crack Cannabinoids (Marijuana, Pot, Hashish) Amphetamines (Crystal Meth, Crank Speed, Ice, Diet Pills, Benzedrine, Dexedrine, Ritalin, Adderall, Methedrine Vyvanse) Hallucinogens (STP, PCP, LSD, Mescaline, Mushrooms, Ayahuasca, Peytone, Acid, Ketamine, Ecstasy) Caffeine (Soda, Tea, Coffee) Nicotine (Tobacco, Dip) Sedatives (Downer, Quaaludes, GHB) Sleeping Pills (Secinal, Ambien, Dalmane, Restoril, Haldol) Tranquilizers (Mellaril, Thorazine, Haldol) Benzodiazepines (Vallum, Librium, Xanax, Ativan, Tranxene, Klonopin, Serax, Centranx) Opiates (Herion, Demerol, Codeine, Methadone, Morphine, Dilaudid, Percodan, Darvon, Lortab, Opium, Percocet, Oxycontin, Soma, Ultram, Vicodin, Hydrocodone) Inhalants (Gasoline, Glue, Freon) Over The Counter Meds Herbal Supplements/Steroids Other Alcohol(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseCocaine/Crack(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseCannabinoids(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseAmphetamines(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseHallucinogens(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseCaffeine(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseNicotine(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseSedatives(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseSleeping Pills(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseTranquilizers(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseBenzodiazepines(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseOpiates(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseInhalants(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseOver The Counter Meds(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseHerbal Supplements/Steroids(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last UseOther (Please Explain)(Required) Other(Required)Age At StartAge Of Regular UseDescribe Pattern (Frequency, duration, amount, type, method of use)Last Use
