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Addiction Health Screening

Has substance use created problems in your relationships (spouse, children, parents, friends)?

Yes

No

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking substances?

Yes

No

Are you unable to get through the week without using substances?

Yes

No

Have you used prescription drugs at higher doses than recommended or needed to obtain a new prescription before the due date?

Yes

No

Have you had "blackouts" or "flashbacks" as a result of substances use?

Yes

No

Have you gotten in trouble at work or lost a job because of substance use?

Yes

No

Have you engaged in illegal activities in order to obtain substances?

Yes

No

Do you ever feel bad or guilty about your substance use?

Yes

No

Are you unable to stop using substances when you want to?

Yes

No

Have you had medical problems as a result of your substance use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?

Yes

No

Thank you for completing the first step in learning about your health and wellbeing. Can we have a CKF staff member reach out to you for next steps?

If yes, email address is collected and a copy of responses goes to the patient email and help now

If no, email address is collected and a copy of responses goes to the patient email

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Building a World of Help, Hope, & Healing

For Patients

Alcohol
Cannabis
Hallucinogen
Inhalant
Opioids
Phencyclidine
Stimulants
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Sedative, Hypnotic, & Anxiolytic

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785-825-6224

617 E. Elm Street, Salina, KS 67401

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