Treatment history Please give full treatment history of detoxes and rehab Ever in City Roads? How many times? Substance Misuse Please state the substances currently used Age first use Route amount frequency substance Second substance substance Fourth substance For ALCOHOL how many days in past 28? days How many units a day? units – Tobacco use Smoker - how many? per day ex-smoker never smoked Has the client ever injected? If YES: is the client currently injecting and what substance? Have they injected in the past 28 days? Are they currently sharing injecting equipment (spoons, filters & water)? If NO: Have they ever shared injecting equipment? Please circle sites used for injecting ARMS / LEGS / FEET / HANDS / GROIN / NECK Has the client been tested and is positive for HIV date HEP B or already immunised? – (please circle) HEP C date – Hep C antibody status positive/negative/unknown – Please add any further details: Any History of TB, please give details: Alcohol Has the client experienced any of the following in relation to alcohol use? Tremors Pins and needles Anxiety Fits/seizures Visual disturbances Confusion
Substance Misuse Please state the substances currently used Age first use Route amount frequency substance Second substance substance Fourth substance For ALCOHOL – how many days in past 28? days How many units a day? units Tobacco use Smoker - how many? per day ex-smoker never smoked Has the client ever injected? If YES: is the client currently injecting and what substance? Have they injected in the past 28 days? Are they currently sharing injecting equipment (spoons, filters & water)? If NO: Have they ever shared injecting equipment? Please circle sites used for injecting ARMS / LEGS / FEET / HANDS / GROIN / NECK Has the client been tested and is positive for (please circle) HIV – date HEP B or already immunised? HEP C – date Hep C antibody status – positive/negative/unknown Please add any further details: Any History of TB, please give details: Treatment history Please give full treatment history of detoxes and rehab Ever in City Roads? How many times? Alcohol Has the client experienced any of the following in relation to alcohol use? Tremors Pins and needles Anxiety Fits/seizures Visual disturbances Confusion
Cranstoun-City-Rds-GDPR-referral-form-5-18-v2.docx