Substance Abuse Questionnaire

Client Satisfaction Survey Form (#6)

First Name

Country

Date of Birth

Phone Number

What substances do you use now, at what doses daily, and how?

What is the longest period you have spent without a substance?

What symptoms occur when you are not using the substance?

Where and how was it treated earlier, what were the results?

Illnesses or did you suffered from (allergies, epileptic attacks, loss of consciousness, hallucinations, depression)?

Note: