Requested
Illustration:
1.
PLEASE NOTE THE CLIENT'S CONDITION:
ALCOHOL ABUSE
ANSWER QUESTION 2 THROUGH TO
7 AND 12 THROUGH TO 14.
DRUG OR OTHER SUBSTANCE ABUSE
ANSWER
QUESTIONS 8 THROUGH 14
2.
DOES THE CLIENT CURRENTLY CONSUME ANY TYPE OF ALCOHOLIC
BEVERAGE?
IF YES, HOW OFTEN AND IN WHAT AMOUNT:
3.
IS THE CLIENT CURRENTLY A MEMBER OF AA OR A SIMILAR
SUPPORT GROUP?
4.
HAS THE CLIENT EVER BEEN HOSPITALIZED,
INSTITUTIONALIZED, OR BEEN AN OUTPATIENT IN AN ALCOHOL
REHABILITATION PROGRAM?
IF YES, LIST TIME OF DISCHARGE: Month
Year
5.
WITHIN THE LAST SIX YEARS, LIST THE OCCASION AND THE
DATE OF DRIVING UNDER THE INFLUENCE (DUI) ARRESTS AND
CONVICTIONS:
NONE
Month
Year
Month
Year
Month
Year
Month
Year
6.
RESULTS OF THE CLIENT'S MOST RECENT LIVER FUNCTION
TESTS:
7.
IS THE CLIENT PRESENTLY TAKING, OR TAKEN IN THE PAST,
ANTI ABUSE OR ANOTHER MEDICATION TO HELP CONTROL
DRINKING?
8.
IS THE CLIENT USING, OR USED IN THE PAST, ANY OF THE
FOLLOWING SUBSTANCES OR DRUGS: (CHECK BOX AND DETAIL
BELOW)
OPIATES/NARCOTICS: HEROIN, CODEINE, DEMEROL, MORPHINE,
ETHADONE,
BARBITURATES: AMYTAL, PHENOBARBITAL
NON-BARBITURATES: PLACIDLY, DORIDEN
QUAALUDE
AMPHETAMINES: BENZEDRINE, DEXEDRINE
METHAMPHETAMINE: COCAINE, CRACK, ICE
HALLUCINOGENS: LSD, PEYOTE, PSILOCYBIN
ECSTASY
MARIJUANA
OTHER SUBSTANCE
AMOUNT AND FREQUENCY
LAST USED: Month
Year
9.
HAS THE CLIENT EVER BEEN TREATED FOR SUBSTANCE ABUSE?
IF YES, Month
Year
PLACE
10.
HAS THE CLIENT EVER BEEN ARRESTED FOR POSSESSION, USE,
DISTRIBUTION OF, OR SALE OF AN ILLEGAL SUBSTANCE?
LAST USED: Month
Year
CITY
STATE
11.
CLIENT'S MARITAL STATUS:
12.
CLIENT'S OCCUPATION
13.
PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG
WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN,
INCLUDE THE DOSAGE AND FREQUENCY OF EACH:
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