Write the fields as: substance; form; amount if known; frequency; last use; recent changes. “Form” means the way you understand the substance, such as beverage, pill, powder, edible, or unknown. Record names from labels when available, but do not identify an unmarked substance by appearance. If the amount is unclear, use a plain estimate such as “unknown,” “one to three pills,” or “shared amount, cannot estimate.”
Frequency should show the pattern rather than hide variation. “Daily” is less informative than “most evenings, with heavier use on weekends.” For last use, include the date and approximate time if possible. Recent changes can include increased or decreased frequency, a new substance, a return to use after a period without it, mixing substances, or a change in route or form. Report the change without deciding what it means clinically.
- Substance name, or “unknown substance”
- Form or route, if known without guessing
- Amount, with units or an honest estimate range or “unknown”<br>Frequency and pattern, including variation by day or week<br>Date and approximate time of last use<br>Changes during