Drug Use

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Drug Use Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
Does the client presently use any drugs other than those prescribed by a physician or those available over the counter?
- Yes
- No
If no, date of last drug use:
Date Format: MM slash DD slash YYYY
If yes, complete table below.
Click the + sign to add more rows.
Type Usual Quantity Frequency of Use How Taken; IV Dates: From - To
Did the client ever use other drugs or more drugs than they currently use?
- Yes
- No
If yes, complete table below.
Click the + sign to add more rows.
Type Usual Quantity Frequency of Use How Taken; IV Dates: From - To
Is the client currently attending N.A. meetings or similar recovery groups?
- Yes
- No
Has the client ever been treated for excessive drug use?
- Yes
- No
If yes, provide date(s) and details:
Any relapses?
- Yes
- No
If yes, provide date(s) and details:
Any legal troubles because of drug use?
- Yes
- No
If yes, provide date(s) and details:
Any driving violations?
- Yes
- No
If yes, provide date(s) and details:
Medications
Click the + sign to add additional medications.
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
Is the client taking or has the client ever been prescribed Suboxone or any other medication to control his/her drug use? If yes, please provide details:
List any other major health problems the client has:
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Type	Usual Quantity	Frequency of Use	How Taken; IV	Dates: From - To

Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Drug Use

Drug Use Questionnaire