If your client has a history of Alcohol or Drug Abuse, please answer the following:



Agent Name:  

Client Name: 

Phone:  

Fax: 
   

1.  Have you ever been treated for alcohol or sustance abuse ?  Yes   No 
Where and when ?  Length of treatment  
Date of last use:  

2.  Are you a member of AA, NA, CA ?  Yes   No  
When did you join ?  How often do you attend ?  


3.  Have you ever taken ANTABUSE ?  Yes   No 
Are you taking it now ?  Yes   No 


4.  Have ever been convicted of any driving related or criminal offenses relating to alcohol 
or substance abuse ? Yes   No If yes, give details:
 


5.  Do you have any medical problem, including liver disease
or elevated enzymes related to your alcohol use ? Yes   No If yes, give details: 



6.  Prior to treatment how long had you used alcohol ? 
How frequently ?  


7.  Have you ever been treated for drug abuse ?  Yes   No 
If Yes - What type of drugs?  


8.  Before treatment how long had you used drugs? 


9.  Do you use any drugs now?  Yes   No 
If Yes - What type of drugs?