REGISTRATION FORM How Did You Hear About IRiS? IRiS Details Another Agency Local Advertising Worker conducting screening: Family Member Friends Date conducted: Other ……………………………………………………………… Basic Details Title: Ethnicity: Surname: Gender: First Name: Nationality: Date of Birth: Sexuality: Gender: Language: Contact Details GP Details Address: Do you have a GP? Yes No Postcode: GP Name: Telephone: Surgery: Mobile: Emergency Contact Details & No: Telephone: Is the GP aware of your current use? Yes No ……………………………………………………………………………… Contact Permissions Permission to send post? Yes No Permission to leave telephone messages? (Please tick if you consent) Voicemail SMS Permission to record your basic details on IRiS database (Theseus)? Yes No Presenting Substance Use Profile (if currently abstinent or on medication only please record previous substance and current medication) Drug Frequency / Amount / Cost / Units / Indicate Primary, Route Age of 1st Use Date of last use Recent use here Secondary etc. Alcohol Use Questions from AUDIT-C Scoring System 0 1 2 3 4 Never Monthly or less 2-4 times per 2-3 times per 4+ per week How do you have a drink containing alcohol? month week How many units of alcohol do you drink on a typical 1-2 3-4 5-6 7-9 10+ drinking day? How often have you had 6 units + (female) or 8 Never Less than Monthly Weekly Daily or almost units + (male) on a single occasion in the last year? monthly daily Score:___________
REGISTRATION FORM How Did You Hear About IRiS? IRiS Details Another Agency Local Advertising Family Member Friends Other ……………………………………………………………… Worker conducting screening: Date conducted: Basic Details Title: Surname: First Name: Date of Birth: Gender: Ethnicity: Gender: Nationality: Sexuality: Language: Contact Details GP Details Address: Postcode: Telephone: Mobile: Emergency Contact Details & No: ……………………………………………………………………………… Do you have a GP? Yes No GP Name: Surgery: Telephone: Is the GP aware of your current use? Yes No Contact Permissions Permission to send post? Yes No Permission to leave telephone messages? (Please tick if you consent) Voicemail SMS Permission to record your basic details on IRiS database (Theseus)? Yes No Presenting Substance Use Profile (if currently abstinent or on medication only please record previous substance and current medication) Drug Frequency / Amount / Cost / Units / Recent use here Route Age of 1st Use Date of last use Indicate Primary, Secondary etc. Alcohol Use Questions from AUDIT-C Scoring System 0 1 2 3 4 How do you have a drink containing alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ per week How many units of alcohol do you drink on a typical drinking day? 1-2 3-4 5-6 7-9 10+ How often have you had 6 units + (female) or 8 units + (male) on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily Score:___________