SUBSTANCE ABUSE HISTORY FORM

Thank you for taking the time to completely fill out this form as it will help us to better understand you and your situation. The information you provide here is confidential and will only be shared with your clinician.

IDENTIFYING INFORMATION
Name / Last / First / Middle
Former Name(s)
Address / Street
City / State / Zip
Telephone / Home: / Cell: / Work:
General / Today's Date / DOB / Age
Number of years of education / Social Security #:
Present Occupation / Employer Name: / Occupation:
Ethnicity / Hispanic or Latino Non-Hispanic or Latino Decline
Race / American Indian Alaska Native Asian White
Native Hawaiian Other Pacific Islander African American Decline
Language / English Spanish Hmong Mandarin Other ______
HEALTHCARE PROVIDER INFORMATION

Do you have a regular physician?

/ ¨ Yes
¨ No / Name Phone
Address ______Do you want a summary sent to this person (as listed above)? ¨ Yes ¨ No
Has a health care provider/healer ever recommended that you reduce or quit alcohol/drug use? Yes No
Were you referred here by someone? / ¨ Yes
¨ No / Who sent you? ______
Address: ______Do you want a summary sent to this person? ¨ Yes ¨ No
What are the major concerns or issues that bring you to our Center? /
List any previous mental health therapy you have had. /

______

Signature of Person Completing Form and Relationship to Client Date

GENERAL MEDICAL
When did you last have a medical checkup? / Date
Have you ever had any of the following problems? / Seizure
Head Injury
High Blood Pressure
Heart Trouble
Kidney Problems
Other: / Yes No
Yes No
Yes No
Yes No
Yes No / Diabetes
Asthma
Thyroid Problems
Liver Problems
High Cholesterol / Yes No
Yes No
Yes No
Yes No
Yes No
Do you have problems with any of the following things in your daily life? / Headaches
Dizziness
Problem Solving Remembering
In relationships with others / Yes No
Yes No
Yes No
Yes No
Yes No / Concentrating
Reading Writing Calculating
Fights, being fired, arrests.
Performing your job/school work / Yes No
Yes No
Yes No
Yes No
Have you ever had any surgery or medical hospitalizations? / Date List:
Have you ever been hospitalized for mental health reasons? / Date List:
Are you currently taking any prescription medication? / ¨ Yes ¨ No
Name of Medication Dose How often taken
Are there other medications that you have used recently? / ¨ Yes ¨ No If Yes, please list below:
Name & location of pharmacy
Have you taken steroid or cortisone-type drugs within the last year? ¨ Yes ¨ No
Have you taken any over-the-counter meds, herbal remedies or supplements in the last month? Yes No
Please list below: ______
Have you ever been on medications (other than those listed above) for "nerves", depression, anxiety, or other psychological issues? ¨ Yes ¨ No
If Yes, please list:
Do you have difficulty falling or staying asleep? ¨ Yes ¨ No If yes specify:
Have you had any injuries, assaults/violence towards you, accidents, or health-related issues related to your substance use?
¨ Yes ¨ No
If sexually active, do you use any contraceptives or protection from sexually transmitted diseases (STD's)? Please specify.
ALLERGIES
Have you ever had allergic reactions to medications: hives, skin rash, breathing problems or other? / ¨ Yes ¨ No If Yes, please list below:
Name of Medication Describe Allergic Reaction
______
______
Are there medications, other than those you are allergic to, you would prefer not to take due to unpleasant side effects?
¨ Yes ¨ No If Yes, please specify which medication and what the unpleasant side-effect was:
CHEMICAL USE
Chemical use most recent 12 months (client self-report)
Primary Drug Use
(Check your drug of choice) / Age of First Use / Most Recent Pattern of use and Duration
How much you use, how often, and do you need more or less to get the same effect? / Date of last use and time, if needed / Withdrawal Potential?
Needs special care? / Method of use
(oral, smoked, snort, IV, etc)
ALCOHOL
CAFFEINE
MARIJUANA/
HASHISH
COCAINE/CRACK
METH/ AMPHETAMINES
HEROIN
SYNTHETICS
INHALANTS
BENZODIAZEPINES
HALLUCINOGENS
BARBITURATES/
SEDATIVES/
HYPNOTICS
OVER-THE-COUNTER DRUGS
NICOTINE
OTHER
Do you use greater amounts of alcohol/other drugs to feel intoxicated or achieve the desired effect? Or use the same amount and get less of an effect? Yes No
Have you ever been to detox? Yes No / When was the first time? / How many times since then? / Date of most recent detox?
Withdrawal symptoms; Have you had any of the following withdrawal symptoms?:
Symptom / Past 12 months / Recent
(past 30 days) / Symptom / Past 12 months / Recent
(past 30 days)
SWEATING (RAPID PULSE) / NAUSEA/VOMITING
SHAKY/JITTERY/TREMORS / DIZZINES
UNABLE TO SLEEP / SEIZURES
AGITATION / DIARRHEA
HEADACHE / DIMINISHED APPETITE
FATIGUE/EXTREMELY TIRED / HALLUCINATIONS
SAD/DEPRESSED FEELING / FEVER
MUSCLE ACHES / UNABLE TO EAT
VIVID/UNPLEASANT / PSYCHOSIS
DREAMS / CONFUSED/DISRUPTED
IRRITABILITY / SPEECH
SENSITIVITY TO NOISE / ANXIETY/WORRIED
HIGH BLOOD PRESSURE
Are you seriously considering addressing your alcohol and/or drug use within the next six months? Yes No
Are you planning to stop or reduce your alcohol and/or drug use in the next 30 days? Yes No
(Perhaps taking small steps to do so)?
Are you now actively remaining abstinent from your use of alcohol and/or drugs? Yes No
Have you ever felt you ought to cut down on your drinking or drug use? Yes No
Have you ever had people annoy you by criticizing your drinking or drug use? Yes No
Have you ever felt bad or guilty about your drinking or drug use? Yes No
Have you ever had a drink or used drugs as an eye opener first thing in the morning Yes No
to steady your nerves, to get rid of a hangover, or to get the day started?
Reasons for drinking/drug use (Check answers that apply)
Like the feeling / To relax or unwind / Partner encourages use
Trying to forget problems / Makes it easier to talk with people / Most friends drink or use
To cope with stress / To cope with family problems / To cope with family problems
To relieve physical pain / To cope with anxiety / To cope with depression
Other (specify)
Have you ever been to an AA/NA or any other 12-Step Support Group?
Do you have a sponsor? / Yes No If yes, date of last meeting ______
Yes No
Any history of suicide in your family? Yes No Or, someone close to you? Yes No
Are thoughts of suicide occurring when under the influence? Yes No
Legal history: List current/recent history of any legal problems related to substance use.
CLIENT CHOICE/EXCEPTIONS
What obstacles exist to participating in treatment? (Time off work, childcare, funding, transportation, pending jail time, living situation)
What particular treatment choices and options would you like to have?
Do you have a preference for a particular treatment program?
Have you had other rule 25 assessments? Yes No
If yes, where and what circumstances?
FAMILY RELATIONSHIPS
Relationship status:
(check as many as apply) / ¨ N/A (Child) ¨ Single ¨ Married ¨ Widow ¨ Divorced
¨ In a significant relationship ¨ Separated from partner Date ______
If you are in a relationship, please complete: / Partner's Name: How long in relationship: ______
Please list all people with whom you currently live with. / Name(s)
/ Age(s)
/ Relationship to person receiving services
Please list parents, brothers and sisters who are not currently living in your home. / Name(s)
/ Age(s)
/ Relationship to person receiving services
Are you adopted? / ¨ Yes ¨ No
How often can you count on the following people when you need someone? / Always supportive / Usually supportive / Rarely supportive / Never supportive / Willing to stop using
Partner/Spouse
Parent(s)/Aunt(s)/Uncle(s)/Grandparent(s)
Sibling(s)/Cousin(s)
Child(ren)
Other relative(s)
Friend(s)/neighbor(s)
Child(ren’s)/father(s)/mother(s)
Support group member(s)
Community of faith members
Social worker/counselor/therapist/healer
Other(specify)
Please describe any family information (current/past) that might be helpful:
·  Mental/chemical health issues
·  Medical issues
·  Deaths in family
·  Divorces, step-parents
·  Any type of abuse/trauma
Are you currently religiously affiliated? / ¨ Yes ¨ No If Yes, what religion?
GOALS OF THERAPY
Main/Current Symptoms?
What goals do you have for your treatment?
MILITARY HISTORY
Branch: / Served from: ______to ______ / Deployment:

10-21-13

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