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Drug Assessment Proforma

Name: ………………………. DOB: …… / …… / …… DATE: …… / …… / ……

Drug

Age First Used

Age Problem Use

Period of Last Use
Amount, Pattern (i.e. ups and downs)
Method of Use (if required)

Date Last Used

Relationship to Current Issue ?

ALCOHOL

.

.

.

.

         
CANNABIS

.

.

.

.

         
OPIOIDS

eg heroin,

methadone,

morphine,

codeine, others

         
AMPHETAMINE

eg speed, XTC,

Ritalin

.

.

         
BENZODIAZEPINEeg Rohypnol, Valium, Temazepam, others

.

         
SOLVENTS

eg glue, toluene, aerosol, petrol, nitrous oxide, amyl nitrate, others

         
LSD (trips) or MUSHROOMS

.

         
TOBACCO

.

         
OTHER

(prescriptions medications, designer drugs)

         

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Assessment Domains (As Related to Dug Use)

Previous Alcohol or other drug treatment ?

NO o YES o
DETAILS:

.

("Liver - physical") Any current drug-related physical health problems?

NO o YES o
DETAILS:

.

("Liver - physical") Any drug overdoses in the past 12 months?

NO o YES o
DETAILS:

.

("Liver - psychological") Any current drug-related psychological health problems?

NO o YES o
DETAILS:

.

("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
DETAILS:

.

("Livelihood - accommodation") Any drug-related problems re: accommodation? (eg short-term, unstable vs stable, comfortable)

NO o YES o
DETAILS:

.

("Livelihood - work & recreation") Has drug use affected your occupation, study, and/or recreation?

NO o YES o
DETAILS:

.

("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
DETAILS:

.

("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
DETAILS:

.

(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
DETAILS:

.

(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
DETAILS:

.

(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
DETAILS:

.

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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: …… / …… / ……

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Other DrugNet Pages in this Subject Heading

Introduction ] Assessment Interview ] [ Assessment Tool ] Case Plan ] Screening ] On-Line Screening ] AUDIT ] CAGE Alcohol Screen ] GROW ] Community Assessment ] Community Plan ] Psycho-Social Assessment ]

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