Substance Use / Addictive Behavior History Addendum
No use last 30 days 1-3 times last 30 days 1-2 times per week 3-6 times per week Daily. Primary Substance Age of First Use: Primary Substance Date of Last Use: Comments: Secondary Substance: (if applicable, select one) None. Crack Khat Viagra Alcohol Ecstasy Marijuana/Hashish Alprazolam (Xanax) Ephedrine Methamphetamine Other Amphetamine ... ................
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