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SUSPECTED SUBSTANCE ABUSER INTERVIEW <br />Date: <br />1) Are you sick? If yes, what are your symptoms? <br />2) Have you recently seen a doctor? If yes, what are you being treated for? <br />3) Are you taking any medication? What kind of medicine are you taking? <br />Did the doctor give you a prescription for this medicine? <br />If no, did you buy this medicine over the counter? <br />When was the last time you took this medicine? <br />Do you have your prescription with you? <br />Do you have any other medicine with you? <br />Note: Make sure you document detailed information regarding any medication. <br />4) Do you have any medical problems? <br />Diabetes? Requiring Insulin? Low Blood <br />Sugar? <br />Epilepsy? <br />5) <br />Do you have a cold? <br />If yes, are you taking cold pills? <br />Cough Medication? <br />Antihistamines? <br />6) <br />Are you using any drugs? <br />What kind? When? <br />Where? <br />How much did you take? <br />Was anyone with you? <br />7) <br />Would you submit to: a breath analysis test, <br />a urinalysis test, and /or a physical examination so <br />that we can make sure you are in good health and able to perform your job safely? <br />8) <br />Will you take a simple coordination test? <br />S) <br />Have you consumed any alcohol today? <br />What? <br />How much? <br />When did you have the first drink? <br />When did you have the last drink? <br />Where? <br />With whom? <br />67 <br />C <br />