DRUG & ALCOHOL TESTING FORM
DRUG & ALCOHOL TESTING FORM
Name
Name
*
First
Last
Date of Birth
Date of Birth
*
/
DD
/
MM
YYYY
Email
*
Company
Over the counter medication details
1. Are you presently taking any over-the-counter medication / drugs? (E.g. painkillers, Sudafed or other cold and flu medication or cough mixtures).
No
Yes
If Yes to question 1 - How many over the counter medications are you currently taking
One
Two
Three
Over the counter Medication 1
Specific Brand Name Medication / Drug
Reason of Medication
Dosage / Strength per day
Time & Date of last dose
How many days did you use it?
Over the counter Medication 2
Specific Brand Name Medication / Drug
Reason of Medication
Dosage / Strength per day
Time & Date of last dose
How many days did you use it?
Over the counter Medication 3
Specific Brand Name Medication / Drug
Reason of Medication
Dosage / Strength per day
Time & Date of last dose
How many days did you use it?
Prescribed medication details
2. Are you presently taking any prescribed medications or drugs? (E.g. painkillers, sedatives, anti-depressants).
No
Yes
If Yes to question 2 - How many over the counter medications are you currently taking
One
Two
Three
Prescribed Medication 1
Specific Brand Name Medication / Drug
Reason of Medication
Dosage / Strength per day
Time & Date of last dose
How many days did you use it?
Prescribed Medication 2
Specific Brand Name Medication / Drug
Reason of Medication
Dosage / Strength per day
Time & Date of last dose
How many days did you use it?
Prescribed Medication 3
Specific Brand Name Medication / Drug
Reason of Medication
Dosage / Strength per day
Time & Date of last dose
How many days did you use it?
Doctor / Physician who prescribed the medication / drug(s):
Other medication details
3. Any other medication / drugs not previously mention above?
I, certify that the specimen accompanying this form is my own and was provided by me to the collector. Further, I certify that all this information on the Drug and Alcohol Testing Form is correct. I also consent to the analysis of the specimen and understand the results will be provided to my employer.
Draw your signature into the box below.
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
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DD
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MM
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