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. |
