SUBSTANCE USE SECTION 03.09.22 FINAL SAVE

SUBSTANCE USE:
Caffeine Use: [select name="caffeineuse" value="Denied.|Endorsed."]
[conditional field="caffeineuse" condition="(caffeineuse).is('Denied.')"]Client denied any caffeine use[/conditional][conditional field="caffeineuse" condition="(caffeineuse).is('Endorsed.')"]Client reported consuming [select name="caffnumber" value="one cup|two cups|three cups|one to two cups|two to three cups|three to four cups|one|two|three"] of [select name="cafftype" value="coffee|soda drink|soda drinks|caffinated tea|energy drink|energy drinks"] a [select name="cafffreq" value="day|week"][/conditional]. [conditional field="caffeineuse" condition="(caffeineuse).is('Endorsed.')"]Client [select name="caffdec" value="denied having concerns with caffeine use|reported concerns related to caffeine use"] and [select name="caffcut" value="denied any desire to decrease caffeine intake|expressed a desire to decrease caffeine intake"].[/conditional]

Tobacco Use: [select name="tobacuse" value="Denied.|Endorsed."]
[conditional field="tobacuse" condition="(tobacuse).is('Denied.')"]Client denied any tobacco use[/conditional][conditional field="tobacuse" condition="(tobacuse).is('Endorsed.')"]Client endorsed smoking approximately [text name="cignum" default=" "] cigarettes a [select name="cafffreq" value="day|week|every other week|once a month|once a year"].[/conditional] [conditional field="tobacuse" condition="(tobacuse).is('Endorsed.')"]Client [select name="tobhaz" value="reported|denied"] smoking cigarettes in hazardous places [select name="hazlocal" value="(i.e., smoking in bed)|(i.e., smoking around flammable chemicals)"][/conditional]. [conditional field="tobacuse" condition="(tobacuse).is('Endorsed.')"]Client [select name="tobdec" value="denied having concerns related to tobacco use|reported concerns related to tobacco use"] and [select name="tobcut" value="denied any desire to decrease or abstain from tobacco use|expressed a desire to decrease tobacco use|expressed a desire for tobacco cessation"].[/conditional]

Tobacco Treatment: [select name="tobactreat" value="Denied.|Endorsed."]
[conditional field="tobactreat" condition="(tobactreat).is('Denied.')"]Client denied any past treatment for tobacco use[/conditional][conditional field="tobactreat" condition="(tobactreat).is('Endorsed.')"]Client reported [select name="tobactreattype" value="quitting “cold turkey” in the past|using nicotine patches in the past|using nicotine gum|using nicotine patches and gum in the past|prescription medication in the past"] to [select name="tobstop" value="decrease|abstain from"] tobacco use for approximately [text name="tobacduration" default="how long"][/conditional].

Alcohol Use: [select name="alcoholuse" value="Denied.|Endorsed."]
[conditional field="alcoholuse" condition="(alcoholuse).is('Denied.')"]Client denied any current alcohol use.[/conditional][conditional field="alcoholuse" condition="(alcoholuse).is('Endorsed.')"]Client reported drinking alcohol [select name="alcofreq" value="one day a week|two days a week|one to two days a week|three to four days a week|seven days a week|once every two weeks|once a month"] and consuming [select name="alconumber" value="one alcoholic beverage|two alcoholic beverages|one to two alcoholic beverages|three to four alcoholic beverages|over four alcoholic beverages|over five alcoholic beverages"] per sitting.[/conditional] [conditional field="alcoholuse" condition="(alcoholuse).is('Endorsed.')"]Client [select name="aldec" value="denied having concerns related to alcohol use|reported concerns related to alcohol use"] and [select name="alcut" value="denied any desire to decrease or abstain from alcohol use|expressed a desire to decrease alcohol use|expressed a desire to abstain from alcohol use"].[/conditional]

Alcohol Treatment: [select name="alcoholtreat" value="Denied.|Endorsed."]
[conditional field="alcoholtreatment" condition="(alcoholtreat).is('Denied.')"]Client denied any past treatment for alcohol use or abuse[/conditional][conditional field="alcoholtreat" condition="(alcoholtreat).is('Endorsed.')"]Client reported [select name="alco_1r" value="voluntarily receiving treatment for alcohol use|being court ordered to received treatment"] through [text name="atlocal" default="place of treatment"][/conditional][conditional field="alcoholtreat" condition="(alcoholtreat).is('Endorsed.')"] for approximately [text name="aduration" default="how long"][/conditional].

Substance Use: [select name="duse" value="Denied.|Endorsed."]
[conditional field="duse" condition="(duse).is('Denied.')"]Client denied any current drug use or abuse[/conditional][conditional field="duse" condition="(duse).is('Endorsed.')"]Client report currently [select name="dmeans" value="smoking|vaping|using"] [select name="dtype" value="cannabis|cocaine|opiods|other"] [select name="dfreq" value="one day a week|two days a week|one to two days a week|three to four days a week|seven days a week|once every two weeks|once a month|once every two months|once a year"][/conditional].
[conditional field="duse" condition="(duse).is('Endorsed.')"]Client [select name="ddec" value="denied having concerns related to substance use|reported concerns related to substance use"] and [select name="dcut" value="denied any desire to decrease or abstain from substance use|expressed a desire to decrease substance use|expressed a desire to abstain from substanceuse"].[/conditional]
Substance Treatment: [select name="dtreat" value="Denied.|Endorsed."]
[conditional field="dtreat" condition="(dtreat).is('Denied.')"]Client denied any past treatment for substance use or abuse[/conditional][conditional field="dtreat" condition="(dtreat).is('Endorsed.')"]Client reported [select name="dtrtyp" value="voluntarily receiving treatment for substance use|being court ordered to received treatment for substance use"] through [text name="trelocal" default="place of treatment"][/conditional][conditional field="dtreat" condition="(dtreat).is('Endorsed.')"] for approximately [text name="ddurduration" default="how long"][/conditional].
SUBSTANCE USE:
Caffeine Use:
.

Tobacco Use:
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Tobacco Treatment:
.

Alcohol Use:


Alcohol Treatment:
.

Substance Use:
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Substance Treatment:
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Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.83, 57 form elements, 16 boilerplate words, 6 text boxes, 30 drop downs, 21 conditionals, 36 total clicks
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