Pacific Family Medicine, LLP

Today's Date * Full Patient Name * Date of Birth *

Alcohol:

Once per year, all our patients are asked to complete this form because these factors can affect your health as well as medications you may take. Please help us provide you with the best medical care by answering the questions below.

How many times in the past year have you had 5 or more drinks in a day?

One drink equals one of the following: 12 ounce Beer, 5 ounce Wine, or 1.5 ounce liquor (one shot). Please choose one.

None 1 or More *

* If you answered 1 or more, please complete Alcohol Screening form (AUDIT)

Drugs:

Recreational drugs include methamphetamines (speed, crystal) cannabis (marijuana, pot), inhalants (paint thinner, aerosol, glue), tranquilizers (Valium), barbiturates, cocaine, ecstasy, hallucinogens (LSD, mushrooms), or narcotics (heroin).

How many times in the past year have you used a recreational drug or used prescription medication for non-medical reasons? Please choose one.

None 1 or More **

** If you answered 1 or more, please complete Drug Screening Questionnaire (DAST)

Mood:

During the past two weeks, have you been bothered by little interest or pleasure in doing things?

Yes *** No

If yes, was it? ***

Several days More than half of the time Nearly every day

During the past two weeks, have you been bothered by feeling down, depressed, or hopeless?

Yes *** No

If yes, was it? ***

Several days More than half of the time Nearly every day

*** If you answered yes to either question, please complete the (PHQ-9) form.