Drug Use History Questionnaire – SCARF Organization Inc

First Name

Last Name

Phone/Mobile

Email

Have you used any illegal drugs in the past three years?

If yes, please specify which drugs and the frequency of use

Have you used any prescription drugs without a prescription in the past three years?

If yes, please specify which drugs and the frequency of use

Have you ever been involved in any drug-related criminal activities?

If yes, please provide details

Have you attended any drug rehabilitation programs in the past three years?

If yes, please provide details

Have you ever tested positive for drugs in a professional setting in the past three years?

If yes, please provide details

How often do you consume alcohol?

Have you ever experienced any legal or professional consequences due to alcohol use in the past three years?

If yes, please provide details

Are you currently under any medical treatment that involves the use of controlled substances?

Medical treatment "Yes" (Specify)

Is there any additional information you would like to provide regarding your drug use or substance use history?

Additional Information "Yes" (Specify)

By signing below, I affirm and accept that all the information provided in this questionnaire is accurate and complete to the best of my knowledge.

Consent / Signature

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Date