Chemical History Use Form

First Name*
Last Name*
Phone Number*
Email Address*
Chemical Use
Alcohol*
Beer, Wine, Liquor
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Cocaine/Crack*
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Cannabinoids*
Marijuana, Pot, Hashish/Crack
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Amphetamines*
Crystal Meth, Crank Speed, Ice, Diet Pills, Benzedrine, Dexedrine, Ritalin, Adderall, Methedrine Vyvance
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Hallucinogens*
STP, PCP, LSD, Mescaline, Mushrooms, Ayahuasca, Peytone, Acid, Ketamine, Ecstasy
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Caffeine*
Soda, Tea, Coffee
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Nicotine*
Tobacco, Dip
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Sedatives*
Downer, Quaaludes, GHB
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Sleeping Pills*
Secinal, Ambient, Dalmane, Restoril, Halcoin
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Tranquilizers*
Mellaril, Thorazine, Haldol
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Benzodiazepines*
Vallum, Librium, Xanax, Ativan, Tranxene, Klonopin, Sera, Centranx
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Opiates*
Heroin, Demerol, Codeine, Methadone, Morphine, Dilaudid, Percodan, Darvon, Lortab, Opium, Percocet, Oxycontin, Soma, Ultram, Vicodin, Hydrocodone
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Inhalants*
Gasoline, Glue, Freon
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Over The Counter Meds*
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Herbal Supplement Steroids*
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)
Other*
Age at Start*
Age of Regular Use*
Last Use*
Describe Use Pattern*
(frequency, duration, amounts, type, method of use)