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Addiction is a disease which, without treatment/recovery, ends in jail, an institution, hospitalization and/or death. The first step
is admitting you have a problem. To help you determine this, fill out the following questionnaire.Congratulations for taking this very important first step on your road to recovery! How old were you when you first used alcohol? __________
How old were you when you first used drugs? __________
Age of first intoxication? __________
Date(s) last use: __________ Type: __________ Amount: __________
Date(s) last use: __________ Type: __________ Amount: __________
Date(s) last use: __________ Type: __________ Amount: __________ Have you ever had legal troubles (arrested, jail, DUI's)? Yes ___ No ___
Does using interfere with your eating or sleeping? Yes ___ No ___
Have you experienced blackouts? Yes ___ No ___
Does it take more to get the same effect? Yes ___ No ___
Does it take less to get the same effect? Yes ___ No ___
Do you usually drink/drug with others? Yes ___ No ___ Longest clean/sober period within the past 6 months: __________
Longest clean/sober period in a lifetime: __________
Have you been diagnosed with any of the following medical problems?
Pancreatitis _____ Heart Trouble _____ Ulcers _____
Esophageal Varices w/ Bleeding _____ Esophageal Varices w/o Bleeding _____
Diabetes _____ Hepatitis _____ STD's _____ Have you ever experienced any of the following withdrawal symptoms?
Seizures _____ DT's
_____ Shakes _____ Sweats _____ Irritability _____
Anxiety _____ Nausea _____ Vomiting _____ Insomnia _____
Intense Dreaming _____ Nightmares _____ Delusions (usually paranoid) _____
Answer the following questions, using the last two years as your time frame:Have you ever felt you should cut down on drinking?
Yes ___ No ___
... or drug use? Yes ___ No ___Have you ever been criticized for drinking? Yes ___ No ___
... or drug use? Yes ___ No ___ Have you ever felt bad or guilty about drinking? Yes ___ No ___
... or drug use? Yes ___ No ___ Have you ever had a drink first thing in the morning (an eye-opener)
to steady nerves or to get rid of a hangover? Yes ___ No ___ If YES to any of the above, an in-depth substance abuse assessment may be indicated.
To schedule a full assessment, call The Kent Center at 401-732-5656. |
