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Clear Form Search Print Page Email Page ALCOHOL USAGE CLIENT NAME: Date: Male Female Date of birth: Height: Weight: Tobacco Use: Never used Totally stopped Date stopped: Use now Type of nicotine product:
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01
Start by providing your personal information such as your name, age, and contact details.
02
Indicate whether you are a current or former alcohol user.
03
Specify the frequency and quantity of alcohol consumption, including any binge drinking habits.
04
Classify the type of alcohol used, whether it is beer, wine, spirits, or a combination of these.
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Provide details on any alcohol-related health issues or incidents, such as liver problems or DUI offenses.
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Answer questions pertaining to any treatment or counseling you have received for alcohol use.
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Include information on any current medications or medical conditions that may be relevant to alcohol use.
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Be honest and accurate when filling out the form, as any discrepancies may affect the assessment or treatment provided.

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Alcohol usage - independent refers to the consumption of alcoholic beverages by individuals acting independently.
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To fill out alcohol usage - independent, individuals must accurately document the amount and frequency of alcohol consumption.
The purpose of reporting alcohol usage - independent is to track and monitor individual alcohol consumption.
Information such as the type of alcohol consumed, quantity, and frequency must be reported on alcohol usage - independent.
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