Non-Psychotropic Allergies/Adverse Reactions/ Sensitivities Check if Yes and List Food Drugs(Rx/OTC/ILLICT) Unknown Allergies Other: Date of last physical Date of last dental exam: exam: Referral made to primary care or specialty NO YES If yes, list: Additional Medical Information: Narrative continued in Addendum SUBSTANCE USE Prenatal AGE AT CURRENT SUBSTANCE USE FIRST None/ Current Current Current In Client-perceived USE Denies Use Abuse Dependence Recovery Problem? SUBSTANCE EXPOSURE, if ever used: ALCOHOL Y N AMPHETAMINES (SPEED/UPPERS, CRANK, ETC) Y N Y N OPIATES (HEROIN, OPIUM, METHADONE) Y N HALLUCIENOGENS (LSD, MUSHROOMS, PEYOTE, ECTASY) Y N SLEEPING PILLS, PAIN KILLERS, VALIUM, OR SIMILAR Y N PSP (PHENCYCLIDINE) OR DESIGNER DRUGS (GHB) Y N Y N INHALANTS (PAINT, GAS, GLUE, AREOSOLS) MARIJUANA/ HASHISH Y N TABACCO/ NICOTINE Y N CAFFEINE (ENGERY DRINKS, SODAS, COFFEE, ETC.) Y N Y N OVER THE COUNDER: OTHER SUBSTANCE: Y N COMPLIMENETARY ALTERNATIVE MEDICATION Y N Is beneficiary receiving alcohol and drug services? Yes, from this provider Yes, from a different provider No If yes, type of alcohol and drug services: Residential Outpatient Community/ Support Group SUSBSTANCE RISKS, USE, & ATTITUDES/EXPOSURE NO YES UNABLE TO ASSESS Were any risk factors identified based on clinical judgment? Does the client currently appear to be under the influence of alcohol or drugs?
Non-Psychotropic Allergies/Adverse Reactions/ Sensitivities Check if Yes and List Food Drugs(Rx/OTC/ILLICT) Unknown Allergies Other: Date of last physical exam: Date of last dental exam: Referral made to primary care or specialty NO YES If yes, list: Additional Medical Information: Narrative continued in Addendum SUBSTANCE USE SUBSTANCE EXPOSURE, if ever used: Prenatal AGE AT FIRST USE CURRENT SUBSTANCE USE None/ Denies Current Use Current Abuse Current Dependence In Recovery Client-perceived Problem? ALCOHOL Y N AMPHETAMINES (SPEED/UPPERS, CRANK, ETC) Y N Y N OPIATES (HEROIN, OPIUM, METHADONE) Y N HALLUCIENOGENS (LSD, MUSHROOMS, PEYOTE, ECTASY) Y N SLEEPING PILLS, PAIN KILLERS, VALIUM, OR SIMILAR Y N PSP (PHENCYCLIDINE) OR DESIGNER DRUGS (GHB) Y N INHALANTS (PAINT, GAS, GLUE, AREOSOLS) Y N MARIJUANA/ HASHISH Y N TABACCO/ NICOTINE Y N CAFFEINE (ENGERY DRINKS, SODAS, COFFEE, ETC.) Y N OVER THE COUNDER: Y N OTHER SUBSTANCE: Y N COMPLIMENETARY ALTERNATIVE MEDICATION Y N Is beneficiary receiving alcohol and drug services? Yes, from this provider Yes, from a different provider No If yes, type of alcohol and drug services: Residential Outpatient Community/ Support Group SUSBSTANCE RISKS, USE, & ATTITUDES/EXPOSURE NO YES UNABLE TO ASSESS Were any risk factors identified based on clinical judgment? Does the client currently appear to be under the influence of alcohol or drugs?
Init_Assessment_Short.docx