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Form27 - [FORM 27Use the top of this page for your...

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[ FORM 27 —Use the top of this page for your letterhead.] Chemical Use Survey Name: Date: In order to treat you effectively, I need information about the ways you and your family have used alcohol, drugs, and/ or other chemicals that can affect you psychologically. So please answer these questions fully. A. What have you used? 1. Think about any and all chemicals you have used,and indicate how much you used (amount) and how often.Then indicate all the effects it had on you (mental, physical, family, legal, etc.). Chemical Age started Last use Over the last 30 days See ques- tion 3, below Amount and how often Effects/consequences Caffeine Tobacco (smoked or chewed) Alcohol Marijuana/THC Cocaine/crack (snorted, injected, or smoked) Inhalants (“Huffing”) LSD Prescribed pills Others: Specify 2. Write “P” above next to your primary drug of choice. 3. For each chemical you currently use,what causes you to stop? Enter one or more of these letters in the last column above: A = The money runs out. B = I use up my supply. C = Personal choice. D = Unconsciousness. E =
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Form27 - [FORM 27Use the top of this page for your...

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