How to Prepare a Substance Use History Before Your First Appointment
- October 28, 2026
- Posted by: editor
- Category: Health Tips
Your first appointment with an addiction psychiatrist will feel like a long interview about your substance use history: what you used, how much, since when, what happened when you stopped. Most people sit in that chair and go blank. Dates blur, quantities shrink, and the seizure from three years ago never gets mentioned.
This guide fixes that. It is a workbook: seven short steps, each with a fill-in table or prompts, that help you write down your substance use history calmly at home. Do it yourself, with a family member, or let family prepare an observation log if you are not ready. Either way, you walk in with paper, not panic.
What is a substance use history, and why does the doctor need it?
A substance use history is a written record of every substance you have used, how much and how often, when it started, what happened when you stopped, past treatment, and your physical and mental health. Doctors use it to plan a safe detox, spot dual diagnosis, choose medicines, and decide whether you need inpatient or outpatient care.
Every question has a practical reason behind it. Here are the three big ones.
1. Safe detox planning
For many people the most dangerous moment is stopping. Daily alcohol and daily sleeping pills can cause fits and severe confusion when stopped suddenly. If the doctor knows you drink a full bottle a day and had a fit last Diwali when you tried to quit, they will plan a supervised medically managed detox with the right medicines and monitoring, rather than sending you home to “just stop”.
2. Spotting dual diagnosis
Many people who drink or use drugs also live with depression, anxiety, bipolar disorder, trauma or sleep problems. Your history helps the team see the pattern and decide whether you need integrated dual diagnosis care that treats both at once.
3. Choosing medicines that are safe for you
Some anti-craving medicines are unsafe with liver damage. Some cannot be started while opioids are still in your body. Some interact with medicines you already take for BP, diabetes or epilepsy. An accurate list protects you from a prescription that does more harm than good.
Is it safe to be honest?
Yes. Your doctor is not the police or your employer. Medical professionals are bound by confidentiality, and the Mental Healthcare Act, 2017 covers alcohol and drug use disorders as mental illness and includes a right to confidentiality for people receiving care. If you are worried about your file, ask the centre how records are stored and who can access them.
Under-reporting is the most common mistake. People halve their quantities out of shame, and get a detox plan built for someone who drinks half as much. Round up, not down.
Important safety box. Do not stop alcohol, sleeping pills or anxiety tablets (benzodiazepines such as alprazolam or clonazepam) abruptly while you are preparing this history. Keep your current pattern steady until a doctor advises you. If you or someone you are with has a fit, becomes confused or disoriented, sees things that are not there, has chest pain, cannot be woken, or is breathing very slowly, call 112 immediately.
Get a notebook or a blank note on your phone. Set aside 45 minutes; you need not finish in one sitting.
Step 1: List every substance, including the ones you think “don’t count”
Write down everything you have used regularly in the last few years, not just the main problem. Combinations matter: alcohol plus sleeping pills carries a much higher risk than either alone.
Use the names you actually use. The doctor has heard them all. Here are common Indian names to jog your memory:
- Cannabis: ganja, charas (hashish), bhang (often in thandai or golis), “maal”, joints, chillum.
- Heroin and opioids: smack, brown sugar, chitta, “safed”.
- Poppy products: doda post, poppy husk, bhukki, afeem (opium).
- Codeine cough syrups: write the brand name and bottle size in ml.
- Painkillers: tramadol, tapentadol, other strips bought without prescription.
- Sleeping pills and anxiety tablets: alprazolam, clonazepam, lorazepam, nitrazepam, zolpidem, “neend ki goli”.
- Inhalants: whitener / correction fluid, glue, petrol, aerosols.
- Stimulants and party drugs: MD (mephedrone or MDMA, “molly”), ecstasy pills, cocaine (“coke”), meth (“ice”, “shard”).
- Alcohol: whisky, rum, beer, desi daru / country liquor, wine, vodka.
- Tobacco: cigarettes, bidi, gutka, khaini, vape. Yes, list it.
Now fill this table. One row per substance. If you are unsure, write a range (“4-6 pegs”) or “not sure” rather than leaving it blank.
Worksheet 1: My substances
| Substance | Since when | How much / how often | Last used |
|---|---|---|---|
| e.g. Whisky | Age 22, daily since 2019 | 6-8 large pegs, every night | Last night, 11 pm |
| e.g. Alprazolam | 2023 | 1-2 tablets (0.5 mg) most nights | Yesterday |
“How often” tells the doctor whether your body is physically dependent; daily and weekend use are very different. “Last used” tells them when withdrawal is likely to begin.
Check tablet strips for the drug name and strength, and bring an empty strip or bottle. It is more reliable than memory.
Step 2: Draw your drug use timeline, decade by decade
A list tells the doctor what you use. A timeline of drug use tells the story: how fast things escalated, what triggered the worst periods, and what helped you cut down.
Do not try to remember every year. Work in big blocks and fill in landmarks.
How to draw it
- Draw a line across a page, from age 10 on the left to your current age on the right.
- Divide it into decades or five-year blocks: teens, 20s, 30s, 40s.
- Mark first use of each substance with a small dot and the age.
- Mark when use became regular (weekly or daily) with a bigger dot.
- Shade the peak periods, the times you used the most.
- Mark every attempt to stop or cut down with an X, and how long it lasted.
- Above the line, write life events: college, first job, marriage, a death in the family, job loss, COVID lockdown, a move to another city.
You will often notice links you never put into words, such as drinking that jumped after a promotion, or pills that started after a parent’s illness. Those links are gold for therapy, especially in a personalised treatment plan that targets your actual triggers.
Prompts to answer under your timeline
- When did I first notice I needed more to get the same effect?
- What is the longest I have gone without using in the last five years? How did it end?
- Has my pattern changed in the last three months? Increased, decreased, switched substance?
A recent switch, say from charas to smack, or to morning drinking, signals that things are moving fast.
Step 3: Record your withdrawal history and every dangerous moment
If you complete only one step thoroughly, make it this one. Your withdrawal history is the clearest predictor of your next withdrawal. Someone who had a fit last time is at real risk of another, and the team needs to know before detox begins.
Alcohol and benzodiazepine withdrawal can cause seizures and delirium, which is why doctors take these questions so seriously. If you want to understand the medical side, read whether alcohol withdrawal can be fatal and the risks of stopping benzodiazepines. Opioid withdrawal is rarely fatal by itself, but it is intensely uncomfortable, and overdose risk rises sharply after a break because tolerance drops.
Worksheet 3: Withdrawal and danger log
| What happened | Yes / No | When (month, year) | Details |
|---|---|---|---|
| Shaking hands in the morning | |||
| Fits / seizures | |||
| Confusion, not knowing where you are | |||
| Seeing or hearing things | |||
| Blackouts (memory gaps) | |||
| Overdose / found unconscious | |||
| Emergency room visit | |||
| Hospital admission | |||
| Injuries, accidents, falls |
In “Details”, note what you were using and what treatment you received. Find any hospital discharge summary and photograph it.
Other withdrawal symptoms worth writing down
- Sweating, racing heart, high BP readings when you skip a day.
- Body aches, runny nose, yawning, diarrhoea, goosebumps (common with opioids).
- Severe insomnia, irritability, panic, intense cravings.
- How many hours after your last use symptoms usually start.
Also note whether you have ever injected. It changes the infection tests and overdose-prevention advice, not the doctor’s respect for you.
Step 4: List past treatment, including what did not work
Past treatment is not a record of failure. It is data, and a plan that builds on what partly worked beats starting from zero.
Worksheet 4: Treatment I have tried
| Treatment / place | When and how long | What helped | Why it ended |
|---|---|---|---|
| e.g. Rehab, Ghaziabad | 2022, 45 days | Group sessions, routine | Left early, family pressure |
| e.g. Disulfiram | 2024, 3 months | Stopped drinking while on it | Stopped taking tablets |
Prompts to fill the gaps
- Have I ever been prescribed naltrexone, disulfiram, acamprosate, baclofen, buprenorphine or methadone? What dose, and did I have side effects?
- Was I ever on an opioid substitution programme at a government hospital or OST centre?
- Did I attend AA, NA or another support group? For how long?
- What was the first thing that went wrong before each relapse?
Be honest about the last one: “I stopped my tablets to drink at my cousin’s wedding” is exactly what a doctor needs to hear. For background on how anti-craving medicines are used, see our guide to medicines used in alcohol addiction treatment, but leave the choice of medicine to your doctor.
Step 5: Health and mental health check
Your physical health decides which detox medicines are safe and whether you need a hospital rather than a rehab setting. Gather your reports first.
Physical health prompts
- Liver: any fatty liver, raised liver enzymes (SGOT/SGPT, GGT), jaundice, swelling in the belly?
- Diabetes, high BP, heart problems, thyroid.
- Stomach: acidity, vomiting blood, black stools, pancreatitis.
- Epilepsy or fits not linked to withdrawal.
- HIV, hepatitis B or hepatitis C tests: done or not, results, dates.
- TB, chest infections or breathing problems.
- Pregnancy, and allergies to any medicine.
Mental health prompts
- Have I ever been diagnosed with depression, anxiety, bipolar disorder, ADHD, psychosis or PTSD?
- Do I have long periods of low mood, panic attacks or very poor sleep, even when I am not using?
- Have I ever had thoughts of ending my life? Have I ever tried? When, and how?
The suicide question is the hardest to write down, and the most important, because mood can dip sharply during detox. If you are having thoughts of suicide right now, do not wait for your appointment: call Tele-MANAS on 14416, which is a free 24×7 government mental health helpline, or 112 in an emergency.
Worksheet 5: Current medicines
| Medicine name | Strength | How often | Prescribed by |
|---|---|---|---|
| e.g. Metformin | 500 mg | Twice daily | Family physician |
Include Ayurvedic, homeopathic and “de-addiction drops” bought online. Some may contain undeclared medicines.
Step 6: How has it affected your life?
This step shows the stakes, and often becomes the motivation you return to on hard days. Short notes only.
- Work or studies: missed days, warnings, lost jobs, failed exams, using at work.
- Money: roughly how much a month goes on substances, loans, borrowing from friends, selling things, credit card debt.
- Relationships: fights at home, separation, children affected, friends you have lost, trust broken.
- Legal: drunk-driving challans, police cases, NDPS matters, court dates. Mention pending dates so treatment can plan around them.
- Safety: driving after using, violence at home.
If relationships at home are badly strained, ask about family counselling sessions as part of your plan; repairing trust is part of treatment, not an afterthought.
Step 7: Write down your goals and your questions
A first appointment is two-way. Write your questions down; you will forget them once the conversation starts.
My goals (tick or write your own)
- Stop completely.
- Cut down while I decide.
- Get through withdrawal safely.
- Sort out my sleep, mood or anxiety.
- Repair things with my family.
Questions to ask the doctor
- Based on my history, do I need inpatient detox, or can this be done as an outpatient?
- Which withdrawal symptoms should I expect, and how will you manage them?
- Which medicines might you use, and what are the side effects?
- Do you think I have a separate mental health condition that needs treatment too?
- How long is the recommended programme, and what happens after discharge?
- What should I do between today and admission to stay safe?
If you are still at the stage of choosing a centre, our sibling guides on what happens on your first rehab admission call and documents needed for rehab admission pair well with this worksheet.
A worked example: Arjun’s completed substance use history
Illustrative example. Arjun is a fictional person created for this guide; any resemblance to a real patient is coincidental.
Arjun is 38, works in sales in Noida, is married with one daughter, and lives with his parents. He booked an assessment after missing his daughter’s school function.
Arjun’s Worksheet 1
| Substance | Since when | How much / how often | Last used |
|---|---|---|---|
| Whisky | Age 19; daily since 2018 | 1 full bottle (750 ml) on weekdays, more on weekends | Last night, around midnight |
| Beer (strong) | Age 18 | 2 bottles (650 ml) in the afternoon, 3-4 days a week | 2 days ago |
| Alprazolam | 2023 | 0.5 mg, 1-2 tablets most nights to sleep | Last night |
| Charas | Age 20 to 27 | Weekends, stopped by himself in 2015 | 2015 |
| Cigarettes | Age 17 | 15-20 a day | This morning |
Arjun’s timeline
- Teens (17-19): First cigarette at 17, first beer at 18 at a college fest, whisky from 19 at hostel parties, weekends only.
- 20s (20-29): Charas with friends from 20. Joined sales at 24; client dinners meant drinking 3-4 nights a week. Stopped charas after marriage at 27.
- 30s (30-38): Daily drinking began in 2018 after a promotion and a big sales target. Peak in 2020-21 during lockdown: morning drinks began. Tried to stop in March 2022; had a fit on day 2 and was taken to a hospital emergency in Sector 62. Disulfiram for 3 months in 2024 helped; he stopped tablets before a family wedding and restarted drinking. Started alprazolam in 2023 from a chemist without a prescription for sleep.
Arjun’s key notes from Steps 3 to 7
- Danger history: One withdrawal seizure (March 2022, emergency visit, discharge summary found). Two blackouts in the last 6 months. Morning hand tremors daily.
- Health: Fatty liver on ultrasound in 2024; SGPT raised. BP borderline. HIV and hepatitis never tested.
- Mental health: Low mood most days for 2 years, wakes at 3 am. No suicide attempts; occasional “what’s the point” thoughts.
- Life impact: Warning letter at work; personal loan of Rs 2 lakh partly used for drinking; daughter avoids him in the evenings.
- Goal: Stop completely, get through withdrawal safely, keep his job.
- Top question: “After my fit last time, do I need to be admitted for detox?”
Within two minutes, the doctor sees heavy daily drinking combined with a benzodiazepine, a previous withdrawal seizure, liver changes and possible depression. Supervised inpatient detox, a mood assessment and liver follow-up become the obvious discussion. Without the paper, Arjun would probably have said “I drink a bit too much in the evenings”.
If you’re preparing it for someone else: the family observation log
Often the person who uses is not ready for a worksheet, and a parent or spouse is booking the appointment. You cannot write their history, but you can write what you have seen.
Rules for a fair observation log
- Write only what you saw or heard. “Found 3 empty quarter bottles under the bed on 12 October” is useful. “He must be drinking a bottle a day” is a guess.
- Do not guess quantities. If you don’t know, write “unknown”. The doctor will ask the person directly.
- Use dates. Even rough ones: “first week of September”.
- Record behaviour, not character. “Shouted and broke a glass at 11 pm” rather than “he is a monster when drunk”.
- Note any emergencies: fits, falls, unconsciousness, hospital visits, with the hospital name.
- Photograph, don’t confiscate in anger. A photo of a strip or bottle helps identify the substance.
- Keep it private. Do not share it in family WhatsApp groups. It is health information about an adult.
Family observation log format
| Date | What I saw or heard | Time of day | What happened after |
|---|---|---|---|
| e.g. 3 Oct | Hands shaking at breakfast, steadied after going out | 8 am | Came back smelling of alcohol |
A note on consent: an adult has the right to make decisions about their own treatment, and a family member’s wish alone does not authorise anyone to admit or hold them. Bring your log to support a conversation, not to force one. If you want help with that conversation, read our guide on ways to help a loved one struggling with addiction. The person can also formally appoint someone they trust to support them; this Nyaaya explainer on appointing a nominated representative sets out how that works under Indian law.
Measuring units Indians actually use, and how to write them for a doctor
Doctors think in millilitres. Most of us think in pegs and quarters. The goal is to translate what you do into something the doctor can calculate from; when in doubt, write your words and the size on the label.
Alcohol
| What you say | Roughly how much | Write it as |
|---|---|---|
| Small peg | 30 ml spirit | “30 ml whisky” |
| Large peg / “patiala” | 60 ml or more | “60 ml whisky” (note if you pour your own) |
| Quarter / quarter bottle | 180 ml | “180 ml rum” |
| Half / pint | 375 ml | “375 ml vodka” |
| Full / bottle | 750 ml | “750 ml whisky” |
| Nip | Varies by state and brand | Check the ml on the label |
| Beer bottle | 650 ml | “650 ml beer, strong or mild” |
| Beer can | 330 or 500 ml | Check the can |
| Desi / country liquor pouch or bottle | Varies | Size in ml, and say “country liquor” |
Also note whether beer is “strong” (check the percentage on the label) and whether home pegs are free-poured. Home pours are usually bigger than you think.
Other substances
For drugs, describe how you buy and use them in your own words. Do not convert anything into milligrams; that is the doctor’s job.
- Smoked cannabis: number of joints or chillums a day, and whether shared.
- Heroin / smack / chitta: how it is bought (“puri”, “packet”, “point”), roughly how much money a day, and whether smoked, snorted or injected.
- Doda post: how many times a day, and how much money you spend on it a week.
- Cough syrup: brand, bottle size in ml, bottles per day.
- Tablets: name, strength printed on the strip, tablets per day.
- Inhalants: how many tubes or bottles a week.
- MD / party drugs: how often (weekends, every night), and spending per session.
Money is a surprisingly good measure. “Rs 800 a day on smack” tells a clinician a lot without anyone estimating weights.
This section is only about describing past use to a clinician. It is not guidance on doses, and nothing here should be read as a safe amount of any substance.
How to share your history with the clinic, safely
Bring a printout
- Print two copies: one for the doctor, one for you to refer to while you talk.
- Staple the timeline, the worksheets, hospital discharge summaries and recent blood test reports together.
Sending it ahead on WhatsApp or email
Some centres ask for reports in advance. Ask first which channel they use for medical records, and send only to the official number or email, never to a staff member’s personal phone or an agent.
- Avoid posting it in any group chat.
- Do not send it from a shared family phone if you want it kept private.
- Ask the centre how they store records and who has access. Health information is sensitive personal data under India’s data protection law, and a good centre will answer this clearly.
On the day
Hand over the paper early: “I’ve written down my substance use history so I don’t forget anything.” The doctor will still ask questions, because they want to hear it in your words. That is normal.
If you are admitted, it shapes your first day of care; see what happens in the first 24 hours after rehab admission.
If you cannot face writing it all
Then fill in only Step 1 and Step 3, the substances and the dangerous moments. A half-finished history beats none. You can also call the national de-addiction helpline 14446, a free, round-the-clock counselling and referral line under the Nasha Mukt Bharat Abhiyaan, if you want to talk it through with someone first.
At Second New Life in Noida, the admissions team can tell you what to bring, and the clinical team uses your history to shape detox, therapy and aftercare around you.
Frequently Asked Questions
What should I tell an addiction doctor at my first appointment?
Tell them every substance you use, how much and how often, when you last used, and what happened when you tried to stop, especially fits, confusion or hallucinations. Add past treatment, current medicines, physical and mental health conditions, and your goals. Honest, rounded-up numbers help the doctor plan safe detox and choose medicines that suit you.
Will my substance use history be shared with my family or employer?
Generally no. Doctors are bound by medical confidentiality, and the Mental Healthcare Act, 2017 recognises a right to confidentiality for people receiving mental health care. Your history is used to treat you. Ask the centre how records are stored, who can access them, and how you can choose what is shared with family members.
What if I can’t remember exact dates or quantities?
Use ranges and landmarks instead. Say “about 6 to 8 pegs” or “around the year my daughter was born”. Doctors work with approximate histories every day. What matters most is the overall pattern, how often you use, when you last used, and any dangerous withdrawal events. If in doubt, round up rather than down.
Should I stop drinking or taking pills before my first appointment?
Not without medical advice. If you drink daily or take sleeping pills or anxiety tablets daily, stopping suddenly can cause seizures or delirium. Keep your pattern steady and let the doctor plan a safe, supervised reduction or detox. If you notice fits, confusion, hallucinations or very slow breathing, call 112 at once.
Can a family member prepare the history on my behalf?
A family member can prepare an observation log of what they have personally seen, with dates, emergencies and behaviour changes, but should not guess quantities. The doctor will still talk to you directly, because only you know your actual use. As an adult, you make decisions about your own treatment, and family input supports that conversation.
Why does the doctor ask about mental health in a de-addiction assessment?
Depression, anxiety, trauma and other conditions often exist alongside alcohol or drug use, and each can worsen the other. Knowing your mental health history helps the team decide whether you need dual diagnosis care, choose medicines safely, and keep you safe during detox, when mood can drop sharply.
Ready to bring your history to someone who will use it well?
Filling in these pages is already a step forward. If you would like to book an assessment, or simply ask what to bring and what happens next, the Second New Life admissions team in Noida is happy to talk it through, share fees in writing and answer questions without pressure. Contact Second New Life or call +91 84481 77994.
This article is general information only and is not medical or legal advice; please consult a qualified professional about your situation, and in an emergency call 112.
