Drug Assessment Proforma
Name: ………………………. DOB: …… / …… / …… DATE: …… / …… / ……
Drug |
Age First Used |
Age Problem Use |
Period of Last Use |
Date Last Used |
Relationship to Current Issue ? |
| ALCOHOL . . . . |
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| CANNABIS . . . . |
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| OPIOIDS eg heroin, methadone, morphine, codeine, others |
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| AMPHETAMINE eg speed, XTC, Ritalin . . |
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| BENZODIAZEPINEeg Rohypnol, Valium, Temazepam, others. | |||||
| SOLVENTS eg glue, toluene, aerosol, petrol, nitrous oxide, amyl nitrate, others |
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| LSD (trips) or MUSHROOMS. | |||||
| TOBACCO. | |||||
| OTHER (prescriptions medications, designer drugs) |
Assessment Domains (As Related to Dug Use) |
| Previous Alcohol
or other drug treatment ? NO o YES o
. |
| ("Liver
- physical") Any current drug-related
physical health problems? NO o YES o
. |
| ("Liver
- physical") Any drug overdoses in the
past 12 months? NO o YES o . |
| ("Liver
- psychological") Any current
drug-related psychological health problems? NO o YES o . |
| ("Lover
- family/social") Any drug-related
problems re: family/social supports? (eg child
abuse/neglect &/or family violence, drug using family/friends vs supportive
family/friends, other relationships, social networks, loss of family or other
networks/supports dur to drug use) NO o YES o . |
| ("Livelihood - accommodation") Any drug-related problems re: accommodation? (eg
short-term, unstable vs stable, comfortable) NO o YES o . |
| ("Livelihood
- work & recreation") Has drug use
affected your occupation, study, and/or recreation? NO o
YES o . |
| ("Livelihood
- financial") Has drug use affected your
financial situation? (eg. ability to provide material
necessities and comforts, ever had to pawn possessions for drugs? etc) NO o YES o . |
| ("Law
- legal & statutory") Has drug use
affected your involvement with the law or child protection/family violence issues? (eg. drink driving, possession, statutory interventions etc) NO o YES o . |
| (Intoxication,
Regular Use, DEPENDENCE) Do you believe you
are dependent or addicted to a drug(s) (Feeling stuck,
drug taking over life, obsession, withdrawal, increased tolerance, feelings of out of
control) NO o YES o . |
| (INTOXICATION,
Regular Use, Dependence) Have you had any
short-term problems resulting from your drug use? (eg.
car accidents, loss of work from hangover, infection such as Hepatitis C, regrettable sex,
etc) NO o YES o . |
| (Stage
of Change) Are you thinking or doing anything
about cutting down or quitting drug use or reducing problems associated with drug use. NO
o YES o . |
Drug Assessment Summary
Type(s) of drug(s) used, how much, how often, methods and degree of dependency:
.
.
Previous or current drug treatment and/or periods of abstinence or controlled drug use:
.
.
Any association between current issue/s (e.g. statutory & child abuse) and drug use?
.
.
Other problems associated with drug use (Liver, Lover, Livelihood, Law - Intox, Reg Use, Dep):
.
.
Degree of support and accommodation:
.
.
Other (e.g. stage of change - does client recognises drug use issues, willingness to work on issues):
.
.
Overall summary including treatment and referral recommendations if required.:
.
.
.
Assessed by:……….............…… Date: …… / …… / …… Reassessment Due: …… / …… / ……
