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Crossroads Behavioral Health Services
1003 Cottonwood Rd
Phone 641-782-8457
Fax 641-782-7048
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Date
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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