Answer the following questions:
Concerns about substance use (alcohol, marijuana, illicit / prescription drugs)? – Select Yes or No to specify if the patient has ever had these concerns.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button 
.
Optionally, select a year and/or enter a description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Optionally, enter up to 60 characters for the description.
In recovery or treatment for substance use? – Select Yes or No to specify if the patient has ever been in recovery or treatment for substance abuse.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or enter a description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Optionally, enter up to 60 characters for the description.
Have you been on a Pain Agreement or utilized Methadone or Suboxone? – Select Yes or No to specify if the patient has ever had an agreement or uses the medications mentioned.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or enter a description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Optionally, enter up to 60 characters for the description.
(Check all that apply) Do you – Select the checkboxes that correspond to the patient’s current habits:
Smoke.
Chew tobacco.
Vape.
Use e-cigarettes.
Use marijuana.
Traditional tobacco.
Aside from traditional tobacco use, would you like help quitting? – Select Yes or No to specify if the patient is interested in getting help.