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ZZZSBIRT Questionnaire (Pre)
Crossroads Behavioral Health Services
210 Russell Street
Phone 641-782-8457
Fax 641-782-7048
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Questionnaire
Drinking alcohol and using drugs other than those required for medical reasons can affect your health. These activities can also affect the medications you take. Please help us provide you with the best possible medical care by answering the questions below.
Alcohol:
One Drink = 12 oz. Beer
One Drink = 5 oz. Wine
One Drink = 1.5 oz . liquor (one shot)
MALE: How many times in the past year have you had 5 or more drinks in a day?
None
1 or more
FEMALE: How many times in the past year have you had 4 or more drinks in a day?
None
1 or more
OVER 65 YEARS: How many times in the past year have you had 4 or more drinks in a day?
None
1 or more
Examples of drugs may include: methamphetamines (speed, crystal); cannabis (marijuana, pot); inhalants (paint thinner, aerosols, glue); benzodiazepines (Valium); barbiturates, cocaine, ecstasy, hallucinogens (LSD, mushrooms); narcotics (opioids); or synthetic cannabinoids (K2, spices) and cathinones (bath salts).
How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?
None
1 or more
SBIRT Score:
* Please type in the score from above here:
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