Cannabis – Benzos – Other – Have you used any substances within the last week? Yes No Now I’m to ask you about symptoms you are currently having related to withdrawal…. Fever Anxiety / Panic Restlessness Sweating Stomach cramps Clammy skin Tremors Goosebumps Runny Nose Tingling Sensations Pins & Needles Hot flashes Cold Chills Nausea / Vomiting Bone / pain Diarrhea Headaches Yawning Loss of Appetite Sensitivity to Numbness Muscle ache or spasm Hyperactive (excessively energetic) Increased appetite or weight gain Feeling of crawling out of skin Fatigued (tired or exhausted) Seizures Section 3: Complications and Relapse History What is your longest period of sobriety? When was this? What event(s) contributed to this relapse? How did you maintain your sobriety during this period? Have you ever experienced DT’s? Yes No Have you ever blacked out? Yes No If yes, how often? When was the last time you blacked out? Have you ever overdosed on drugs or alcohol? Yes No
Cannabis – Benzos – Other – Have you used any substances within the last week? Yes No Now I’m to ask you about symptoms you are currently having related to withdrawal…. Fever Anxiety / Panic Restlessness Sweating Stomach cramps Clammy skin Tremors Goosebumps Runny Nose Tingling Sensations Pins & Needles Hot flashes Cold Chills Nausea / Vomiting Bone / pain Diarrhea Headaches Yawning Loss of Appetite Sensitivity to Numbness Muscle ache or spasm Hyperactive (excessively energetic) Increased appetite or weight gain Feeling of crawling out of skin Fatigued (tired or exhausted) Seizures Section 3: Complications and Relapse History What is your longest period of sobriety? When was this? What event(s) contributed to this relapse? How did you maintain your sobriety during this period? Have you ever experienced DT’s? Yes No Have you ever blacked out? Yes No If yes, how often? When was the last time you blacked out? Have you ever overdosed on drugs or alcohol? Yes No
DS-Preassessment.docx