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Health Screening

Alcohol
How often did you have a drink containing alcohol, even beer or wine, in the past year?
- 1 Time
- 2 - 4 Times
- 4 - 8 Times
- 8+ Times
How many drinks do you have on a typical day when you drink?
- 1 Drink
- 2 - 3 Drinks
- 4 - 6 Drinks
- 7+ Drinks
How often did you have 5 (for men) 4 (women) or more drinks on one occasion in the past year?
- 1 Time
- 2 - 3 Times
- 3 - 4 Times
- 5 + Times
Has anyone else ever thought you might have a problem with alcohol?
- Yes
- No
Have you or someone else ever been injured as a result of your drinking?
- Yes
- No
Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?
- Yes
- No
Prescription Medication Misuse
Have you ever taken prescription medication that was not prescribed for you?
- Yes
- No
Have you ever taken prescription medication in a way that was not prescribed?
- Yes
- No
Have you ever taken prescription medication only for the feeling or experience that it caused?
- Yes
- No
Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?
- Yes
- No
Drugs
Have you ever used drugs such as marijuana, heroin, cocaine, PCP, LSD, methamphetamine, ecstasy?
- Yes
- No
Which have you used in the past 3 months?
How much are you using per day? When did you last use?
Have you ever used any drugs by injection?
- Yes
- No
Have you ever experienced negative consequences due to your use, that effected any of the following areas; Legal, financial, family, employment, physical health?
- Yes
- No
Score
** Based on your responses to the questions above, a + screen to any of the above questions may indicate the need for a more comprehensive assessment to help determine if you or someone you care about may have a Alcohol, Prescription or Drug abuse problem. Please feel free to contact our nearest Outpatient location to schedule an evaluation. All information is confidential and protected by HIPAA and Federal confidentiality laws
Name
First Last
Phone
Email
Would you like to be contacted by phone or email?
- Phone
- Email
- Do not contact

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CONTACT

Arms Acres

75 Seminary Hill Road Carmel, NY 10512

Phone: 8452253400

Directions Toll Free Phone: (888) CARING1
eFax: 845-698-4046
845-698-4084

Certifications

Arms Acres is licensed by the Joint Commission, who ensures quality of care and safe practices and also by the New York State Office of Alcoholism and Substance Abuse Services (OASAS).

Copyright © 2020 · Arms Acres · Developed by Ember Networks

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