Addiction Rehab (Home) | Addiction Treatment

Addiction Assessment

1	Is the person in their teens or female? Yes No

2	Has the person ever been sent to detox, or hospitalized for drug or alcohol related symptoms? Yes No

3	Does the person seek regular medical care? Yes No

4	Has the person had a recent physical examination, or other evaluation to check for anemia, liver and kidney function.? Yes No

5	Does the person have liver problems? Yes No

6	Does the person have kidney problems? Yes No

7	Does the person have heart problems? Yes No

8	Has the person ever had a blackout? (A time when they do not remember the events of the previous day.) Yes No

9	Does the person have changes in their sleep patterns, such os insomnia or fatigue? Yes No

10	Does the person experience shakiness? (Especially noticeable in the hands.) Yes No

11	Does the person experience substance related vomiting or nausea? Yes No

12	Does the person experience abnormal sweatiness? Yes No

13	Does the person experience cramping? Yes No

14	Has the person ever had convulsions? Yes No

15	Does the person ever experience anxiety? (mental) Yes No

16	Does the person have diabetes? Yes No

17	Is the person inclined to lose control of their behavior when using a substance? Yes No

18	Does the person have a diagnosis of mental health disease? Yes No

19	Has the person ever been in mental health treatment? Yes No

20	Is the person currently in mental health treatment? Yes No

21	Is the person normally prone to violence? Yes No

22	Does the person normally exhibit physical anxiety or insomnia? (Anxiety = shortness of breath, nervous sweat, or unusual phobia) Yes No

23	Does the person normally experience depression? Yes No

24	Does the person have grief and loss in their life? Yes No

25	Does the person have hopelessness, preoccupation with death, or destructive tendencies? Yes No

26	Is the person inclined to give away things of personal value? Yes No

27	Does the person experience abnormal sleepiness? Yes No

28	Has the person ever attempted suicide? Yes No

29	Do you believe the person has ever been physically, emotionally, or sexually abused? Yes No

30	Do you believe the person is currently being abused in any way? Yes No

31	Does the person fight with their family of origin? Yes No

32	Does the person have less than 3 friends (close) who do not use drugs or alcohol? Yes No

33	Does the person get into trouble at school or work? Yes No

34	Does the person drink alcohol? Yes No

35	Did the person start drinking as a teen? Yes No

36	Has the person been drinking 1 or more days per week for 10 years or more? Yes No

37	Has the person's alcohol consumption increased over the last 3 years? Yes No

38	Do you think the person is preoccupied with alcohol? Yes No

39	Does the person have 'blackouts' when they drink? Yes No

40	Does the person drink to stop withdrawal? (For a hangover, or to remove shakiness) Yes No

41	Does the person drink more than a six pack of beer, three mixed drinks, or four glasses of wine at a time? Yes No

42	Has the person ever tried to stop or lessen their drinking and failed? Yes No

43	Has the person had 2 or more DUI's? Yes No

44	Has the person lost a job, been absent or late due to drinking? (Answer 'Yes' for absent or late if more than once, or recently.) Yes No

45	In your opinion does the person think their drinking is a problem? Yes No

46	Does the person use Methamphetamine? Yes No

47	Does the person use Cocaine? Yes No

48	Does the person use heroin? Yes No

49	Does the person snort Cocaine or Methamphetamine? Yes No

50	Does the person smoke Cocaine, Methamphetamine, or heroin? Yes No

51	Does the person inject Cocaine, Methamphetamine, or heroin? Yes No

52	Does the person use more than $25 per day of Cocaine, Methamphetamine, or heroin? Yes No

53	Does the person smoke Marijuana? Yes No

54	Does the person smoke 2 or more bowls a day? Yes No

55	In your opinion does the person believe Marijuana helps them sleep better? Yes No

56	Does the person use any other substance regularly? (More than 1x per month, excluding alcohol and tobacco) Yes No

57	Did the person begin using any substance as a teen? (Excluding alcohol and tobacco) Yes No

58	Has anyone ever complained about the person's use of any substance? (Excluding alcohol and tobacco) Yes No

59	Has the person used any substance for more than 10 years? (Excluding alcohol and tobacco) Yes No

60	Does the person use any substance on breaks at work or school? (Excluding tobacco) Yes No

61	Does the person try to hide their use or amount of use from any one? (Excluding tobacco) Yes No

62	Has the person ever lost friends because of their use? (Excluding tobacco) Yes No

63	Does the person miss family or other important events so they can use a substance? (Excluding tobacco) Yes No

64	Does the person isolate and use alone? Yes No

65	Has the person's use at one time increased over the last two years? Yes No

66	Has the person ever been to AA, NA, or any other recovery group/program? Yes No

67	Is the person often fired from jobs due to use? Yes No

68	Does the person associate with a church or have a strong belief system? Yes No

69	Do you believe the person would like help? Yes No

70	Do you believe the person has developed a tolerance for any substance? Yes No

71	Has the person had any noticeable withdrawal symptoms from any substance? Yes No

72	Do you believe the person use longer or consumes more of any substance than they intended to? Yes No

73	Is a large portion of the person's time spent finding, using or recovering from use of any substance? Yes No

74	Does the person give up social, occupational, or recreational events to use any substance? Yes No

75	Does the person continue to use the substance(s) despite medical or psychological advice to quit? Yes No