Mentor Drug Use History Questionnaire Step 1 of 3 33% Personal Information:Name(Required) First Last Email(Required) Drug Use History:Have you used any illegal drugs in the past three years?(Required)NoYesIf yes, please specify which drugs and the frequency of use: Have you used any prescription drugs without a prescription in the past three years?(Required)NoYesIf yes, please specify which drugs and the frequency of use: Have you ever been involved in any drug-related criminal activities?(Required)NoYesIf yes, please provide details Have you attended any drug rehabilitation programs in the past three years?(Required)NoYesIf yes, please provide details Have you ever tested positive for drugs in a professional setting in the past three years?(Required)NoYesIf yes, please provide details How often do you consume alcohol?(Required) Never Occasionally Frequently Daily Have you ever experienced any legal or professional consequences due to alcohol use in the past three years?(Required)NoYesIf yes, please provide details Additional Information:Are you currently under any medical treatment that involves the use of controlled substances? Is there any additional information you would like to provide regarding your drug use or substance use history? By signing below, I affirm that all the information provided in this questionnaire is accurate and complete to the best of my knowledge.
