Identify the specific type of drug or substance

Describe the frequency of usage as:

• Use
• Abuse
• Dependence
• In remission

Describe mode of nicotine use as cigarettes, chewing tobacco, pipe, and/or gum

Specify intoxication/withdrawal as “Uncomplicated” or “With delirium”

Document any withdrawal symptoms

Document any associated diagnoses/conditions

List the blood alcohol level, if available

State “no related complications,” when applicable

Document any related mood disorder

Document any delusions, hallucinations, anxiety, sleep disorders, sexual dysfunctions, or other related conditions

List any treatment provided:

• Detoxification services
• Counseling
• Psychotherapy
• Medication management
• Pharmacotherapy