Substance Use Screening Form
Substance use screening that records self-reported tobacco, alcohol and drug use, patterns and concerns raised, without scoring, grading or diagnosing.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 14 questions, 2 pages, 4 conditional rules.
- Questions
- 14
- Pages
- 2
- Layouts
- classic · card
- Time to complete
- ≈ 4 min
- Conditional rules
- 4
Searches this template answers
- substance use screening form
- substance use questionnaire
- alcohol and drug use form
- tobacco use screening form
- substance use history form
- clinic substance use intake
Also filed under
Live preview and test console
This is the real form. Answer it to test the 4 conditional rules — nothing is sent or stored.
Page 1 of 2 — About your use
3 questions are hidden by conditional logic right now — change an answer above to reveal them.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
Who this template is for
Substance Use Screening Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 14 questions across 2 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 9 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It pins the request to a specific date.
- Conditional logic hides 4 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Substance Use Screening Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 4 conditional rules ship with it.
- Features advanced show logic: if “Do you currently use tobacco products?” is Yes, the form dynamically exposes “Which products, and how often?”. Otherwise that question never appears.
- Features advanced show logic: if “Do you drink alcohol?” is Yes, the form dynamically exposes “How often, and how much on a typical occasion?”. Otherwise that question never appears.
- Features advanced show logic: if “Do you use any recreational or non-prescribed drugs?” is Yes, the form dynamically exposes “Which substances, and how often?”. Otherwise that question never appears.
- Features advanced show logic: if “Has anyone expressed concern about your use of alcohol or other substances?” is Yes, the form dynamically exposes “Describe what was said”. Otherwise that question never appears.
- All 4 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
This form records what a patient reports about their own tobacco, alcohol and other substance use, in their own words and at their own pace. Page one asks directly and plainly about each of the three areas: tobacco products, alcohol, and non-prescribed or recreational drugs, opening a short follow-up box only when the answer is yes so the patient can say which substances and how often without writing more than that. Page two turns to pattern rather than amount: whether anyone has expressed concern about the patient's use, whether the patient has tried to cut down before, and whether any of these substances are being used to cope with stress, pain or sleep. A closing box lets the patient add anything else they want the care team to know. The form does not calculate a score, assign a risk level, or suggest a diagnosis; it is a written record of self-reported use for the clinician to read and act on using their own judgment.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — About your use
- Patient full namerequired
- Date of birthrequired
- Date completedrequired
- Do you currently use tobacco products?required
- Which products, and how often?
- Do you drink alcohol?required
- How often, and how much on a typical occasion?
- Do you use any recreational or non-prescribed drugs?required
- Which substances, and how often?
Page 2 — Patterns and impact
- Has anyone expressed concern about your use of alcohol or other substances?required
- Describe what was said
- Have you ever tried to cut down or stop?required
- Do you use any of these substances to cope with stress, pain or sleep?required
- Anything else you want the care team to know
14 questions in total.
Example of a completed substance use screening form
A sample record showing how a patient reports their own tobacco and alcohol use during an intake.
- Patient full name
- Grant Okafor
- Do you currently use tobacco products?
- No
- Do you drink alcohol?
- Yes
- How often, and how much on a typical occasion?
- A few times a week, two to three drinks
- Do you use any recreational or non-prescribed drugs?
- No
- Has anyone expressed concern about your use of alcohol or other substances?
- No
- Have you ever tried to cut down or stop?
- No
- Do you use any of these substances to cope with stress, pain or sleep?
- Yes
Sample data — no real people, addresses or records are shown. This example does not diagnose or grade the answers shown.
How the form changes as it's filled in
This template ships with 4 conditional rules, grouped into 4 behaviours driven by 4 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Do you currently use tobacco products?”
- Reveals questions
If “Do you currently use tobacco products?” is Yes, the form reveals “Which products, and how often?”.
Driven by “Do you drink alcohol?”
- Reveals questions
If “Do you drink alcohol?” is Yes, the form reveals “How often, and how much on a typical occasion?”.
Driven by “Do you use any recreational or non-prescribed drugs?”
- Reveals questions
If “Do you use any recreational or non-prescribed drugs?” is Yes, the form reveals “Which substances, and how often?”.
Driven by “Has anyone expressed concern about your use of alcohol or other substances?”
- Reveals questions
If “Has anyone expressed concern about your use of alcohol or other substances?” is Yes, the form reveals “Describe what was said”.
Set it up step by step
- 1
Introduce it as confidential and non-judgmental
A short line before the form saying answers inform care, not judgment, gets more honest responses than the questions alone.
- 2
Read it as a starting point for conversation
The form records what was reported; a follow-up conversation is where the clinician actually explores it further.
- 3
Never total or grade the answers
This form is a record, not a scored instrument; do not add up yes answers into a risk category.
- 4
Keep the closing box genuinely open
Some patients say more in their own words in that box than in any of the structured questions above it.
Mistakes to avoid
- Turning the form into a scored screening tool by counting or weighting the answers.
- Assuming a 'no' answer closes the topic rather than one point in an ongoing conversation.
- Skipping the coping question, which often surfaces use that a direct 'do you use drugs' question does not.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Have the clinician review the answers before or during the visit, follow up directly on anything flagged, and keep the record with the patient's chart as background, not as a diagnosis.
Works in both layouts
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Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
Does this form diagnose a substance use disorder?
No. It records what the patient reports; any diagnosis or clinical assessment is made separately by a qualified clinician, not by this form.
Is there a score at the end?
No. The form does not total, weight or grade the answers in any way; it is a plain written record for the clinician to read.
Can a patient decline to answer?
Yes, and the drug use question includes a 'prefer not to say' option for that reason; a declined answer is still a valid, recorded response.
Who should see these answers?
Limit access to the care team involved in the patient's treatment and handle the record with the same confidentiality as the rest of the chart.
Is the Substance Use Screening Form template free to use?
Yes. You can preview and test Substance Use Screening Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Substance Use Screening Form template ask for?
It asks 14 questions across 2 pages, 9 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Substance Use Screening Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
4 conditional rules ship with the template: Features advanced show logic: if “Do you currently use tobacco products?” is Yes, the form dynamically exposes “Which products, and how often?”. Otherwise that question never appears. Features advanced show logic: if “Do you drink alcohol?” is Yes, the form dynamically exposes “How often, and how much on a typical occasion?”. Otherwise that question never appears. Features advanced show logic: if “Do you use any recreational or non-prescribed drugs?” is Yes, the form dynamically exposes “Which substances, and how often?”. Otherwise that question never appears. All rules are editable in the Logic tab.
Where do responses to the Substance Use Screening Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Substance Use Screening Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
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