Your Name
Your Phone
Your Email
Your Date of Birth
HEALTH & MEDICAL TREATMENT HISTORY
Are you discharging from medical detox and/or an inpatient facility? Yes No
If yes, please include the date of admission, discharge date, name of program, the reason for and duration of stay.
Were you previously assessed for substance use at another outpatient facility? Yes No
If yes, please include date, location, and reason for assessment.
Was the treatment and/or assessment related to a legal charge or court order? Yes No
If yes, please include the type of charge, conviction status, and state in which the charge occurred.
Within the last 12 months, have you been treated or diagnosed with any of the following (select all that apply and explain):
Seizures Diabetes High Blood Pressure Heart Disease Bipolar Depression Bowel Problems Schizophrenia Ulcers Hepatitis Cirrhosis Chest Pain Cancer Shortness of Breath Infectious Diseases Liver Problems Kidney Problems Lung Problems Abscess Serious Infections Pancreatitis Head Injury Surgery Broken Bones TB HIV STD's Psychiatric Hospitalization Suicide Attempts Addictions Eating Disorders Visual Impairments Hearing Impairments Speech Impairments Threatened/Harmed Others Other (please explain) None
Comments
Do you have any allergies? Yes No
If yes, what type and is an EpiPen needed?
Do you have any disabilities None Hearing Visual Ambulatory Other (please explain)
Comments
Have you been tested for HIV? Yes No
If yes, when, and were results positive or negative?
Have you been tested for TB? Yes No
If yes, when, and were results positive or negative?
Have you been tested for Hepatitis? Yes No
If yes, when, and were results positive or negative?
Please list any over the counter and/or prescribed medications that you may be taking or prescribed and not taking (please include medication name, dosage, instructions & reason for and duration of a prescription)
Do you have any concerns about your medications? Yes No
If yes, please explain
Are you required to be on a special diet by your doctor? Yes No
If yes, please explain
Are you pregnant? Yes No
Comments
Date of last physical exam
Outcomes of physical exam
Total admissions to the hospital and reason for admission
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SOCIAL & ENVIRONMENTAL HISTORY
How old are you?
Describe your relationship status
Describe your gender identity & sexual orientation
How many children do you have (include age, gender, and custody status)?
Where do you reside and with whom?
Please describe the use of and/or access to alcohol and drugs in the home
How has substance use affected your family, peer, and social relationships?
What is your current education status (include a description of the program if currently enrolled in school)?
What is your current employment status (include the place of employment, position, length of employment and/or unemployment, and reason for unemployment, if applicable)?
How has substance use affected your education or employment?
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MENTAL HEALTH HISTORY
Have you experienced any of the following traumatic events (select all that apply)?
Bullying Emotional Abuse Non-Partner Physical Abuse Sexual Assault or Abuse Violence Neglect Other None
If yes, including when it occurred and a description of the services received, as a result:
Have you ever been diagnosed with depression, bipolar disorder, anxiety, or other mood disorder? Yes No
If yes, include severity and duration
Have you ever experienced hallucinations and/or been diagnosed with schizophrenia or other psychotic disorder? Yes No
If yes, include the age of onset, involvement of substance use, and type of hallucination
Are you having, or have you ever had thoughts, of harming yourself or anyone else? Yes No
If yes, include thoughts or attempts at suicide or homicide, and the number of hospitalizations due to suicidal or homicidal ideation
Are you currently seeing a therapist and/or psychiatrist? Yes No
If yes, include name, the reason for services, frequency of visits, and last visit
Have you previously received mental health treatment? Yes No
If yes, include reason, types of services, location, and date of services
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SUBSTANCE USE HISTORY
Do you have a family history of substance use issues (select all that apply)? Yes, Immediate Relatives Yes, Extended Relatives No Biological History Known None
Comments
Have you ever felt you should stop, or tried to stop, cut down, or control your substance use? Yes No
If yes, explain when & why.
What is your longest period of voluntary abstinence from the mind or mood-altering substances & why.
Have you ever been admitted to a hospital for medical detoxification from a substance? Yes No
If yes, include how many times, when and where.
Are you currently, or have you ever attended a mutual-help support group such as AA, NA, or another support group? Yes No
If yes, include which type and how often you attended
Have you ever felt annoyed by people criticizing your alcohol or drug use? Yes No
If yes, please explain
Have you ever felt guilty about your use of alcohol or drugs? Yes No
Please explain
Over time, have you needed to increase your consumption of alcohol or drugs to get the same effects? Yes No
If yes, specify which substance(s)
Have you ever used alcohol or drugs to alleviate a hangover? Yes No
If yes, include how often, what substance(s), and last occurrence.
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SUBSTANCE USE HISTORY
When was your last use of drugs or alcohol (include all substances)
In the days following your last date of substance use have you experienced any of the following (select all that apply)? Nausea Insomnia Irritability Anxiety Shakiness Decreased Appetite Agitation Craving Other (please explain) None
If yes, specify for what substance(s)
What negative consequences have you experienced as a result of your substance use?
Please indicate any substances that you have experimented with or used on a regular basis.
Alcohol Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount.
Benzodiazepine, Tranquilizers, Barbituates Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Cannabis Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Cocaine, Crack Cocaine Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Hallucinogens, LSD, Mushrooms, Ecstasy, PCP Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Heroin, Opium, Methadone, Presciption Pain Pills Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Inhalants, Nitrous, Freon, Duster, Paint Thinner, Whip-Its Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Methamphetamine, Amphetamine Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Cigarettes, Cigars, Dip, E-cigarettes Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Synthetic or Other Drugs, Spice, K2, Bath Salts Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Caffeine (Pills or Powder) Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
Over the Counter Drugs, Cough Syrup, Tripple C’s Yes No
If yes, specify the age of first use, average amount, frequency of use, date of last use & last used amount
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