Alcohol and Drug Services, Inc.

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(570) 820-8888

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Risk Assessment Questionnaire

For Mothers-To-Be

Check All that Apply:
- I drink alcohol (beer/wine/liquor) in any amount during my pregnancy.
- I use illicit drugs (illegal drugs) in any amount during my pregnancy, including marijuana.
- I use drugs intravenously, intramuscularly, or subcutaneously (skin-popping) during my pregnancy.
- I use over-the-counter medications and preparations in any amount during my pregnancy.
- I smoke cigarettes in any amount during my pregnancy.
- I drink 3 or more cups of coffee per day during my pregnancy.
- I engage in or participate in unsafe sexual practices during my pregnancy (unprotected sex of all types, sex with multiple partners, etc.)
- I engage in sex with known drug users.
- I engage in sex with drug users who use drugs intravenously, intramuscularly, or subcutaneously (skin-popping).
- I use prescription medications that my physician has not prescribed and is, therefore, unaware that I am taking.
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WVADS Inc. Location

WVADS,Inc
437 North Main Street
Wilkes-Barre, PA 18705-1613
Phone: 570-820-8888

49 South Main Street
Pittston, PA 18640
Phone: 570-655-3900

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