Mission Unity Recovery House
| Name: ________________________________________ | Date: _______________________ |
| Provide the date and type of last substance abuse or use of any kind. Include any and all illegal, legal, prescription or non-prescription drugs including those regularly taken and prescribed under a doctor's care. ALCOHOL is a DRUG and must be included on the list |
| Substance | Last Used |
| _______________________________ | _________________________________ |
| _______________________________ | _________________________________ |
| _______________________________ | _________________________________ |
| _______________________________ | _________________________________ |
| _______________________________ | _________________________________ |
| _______________________________ | _________________________________ |
| _______________________________ | _________________________________ |
| _______________________________ | _________________________________ |
| _______________________________ | _________________________________ |
| Signature: ______________________________ | Date: _____________________ |