Alcohol/Drug History – Luzio & Associates Behavioral Services, Inc.

Luzio & Associates Behavioral Services, Inc.
Alcohol/Drug History

Client:

Date:

Fill in this chart for all substances you have EVER used.

Alcohol

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Marijuana

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Tranquilizers (Valium, Xanax, etc.)

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Diet Pills

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Cocaine

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Sleeping Pills

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Methamphetamine (crank)

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Pain killers/narcotics

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Hallucinogens (LSD, PCP)

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Inhalents (glue, gas, etc.)

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Caffeine, energy drinks, OTC meds

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

Other

Type of Drug

Age first used?

When last used?

How often used?

How much used each time?

I am currently alcohol/drug free for the past

Comments:

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I have tried to quit alcohol/drugs before.

If yes, what is the longest time you have stayed sober?

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I sometimes drink/use more than I intend to.

Comments:

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My usage has caused a problem in my life (legal, family job, money, etc.)

If yes, what problems?

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I have had people tell me to quit or cut down.

If yes, who?

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It takes more alcohol/drugs than it used to for me to feel an effect.

Comments:

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I have had memory lapses (blackouts) before when under the influence.

Comments:

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I have trouble sleeping if I don't drink/take something.

Comments:

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I have injected drugs one or more times.

What drugs?

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I sometimes have withdrawal symptoms when I stop using.

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I have snorted drugs one or more times.

What drugs?

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I have been to AA/NA, alanon or alateen meetings before.

How many meetings?

Have you had a sponsor?

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I think I may have a problem with alcohol/drugs.

Comments:

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Others in my immediate family or my close friends abuse alcohol or drugs.

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What type of alcohol or other drugs do you prefer to use? (beer, cocaine, etc.)

What would be the hardest part(s) of stopping all alcohol/drug use?

Which friends/family members would support you in a decision to remain drug/alcohol free?

Client's Signature

Parent/Guardian Signature

Luzio & Associates Behavioral Services, Inc.Alcohol/Drug History

Luzio & Associates Behavioral Services, Inc.
Alcohol/Drug History