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Annual questionnaire
Once a year, all our patients are asked to complete this
form because drug  and  alcohol  use can affect your
health as well as medications you may take.
Please help us provide you with the best medical care
by answering the questions below.


Patient name:

Date of birth:

Are you currently in recovery for alcohol or substance use?              Yes            No

 Alcohol:
One drink =
12 oz.


beer

5 oz.
wine
1.5 oz.
liquor
(one shot)

None
1 or more

MEN:   How many times in the past year have you had 5 or more
drinks in a day?

WOMEN:   How many times in the past year have you had 4 or more
drinks in a day?

Drugs: Recreational 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 nonmedical reasons?
None
1 or more

Developed by SBIRT Oregon, http://www.sbirtoregon.org/resources/annual_forms/Annual%20-%20English.pdf