Please enable JavaScript in your browser to complete this form.We are asking these questions to provide better health care for you. Your health includes your entire being including mental health, behavior health, and substance use. These questions are important for us to provide the best care possible for you. Your answers on this form will remain confidential. Client ID: *Sex: *Select One AnswerMaleFemaleDate of Birth: *Interviewer: *Alcohol How many times in the past year have you had 5 or more drinks in a day? *How many times in the past year have you had 4 or more drinks in a day? *Other Substances How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons (for example, because of the experience or feeling it caused)? *Submit
