Example Of A Psychosocial Assessment Page 2

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Current Medication List
Medication
Dose
Frequency Prescriber
Reason
Past Medication List
Medication
Dose
Frequency Reason Started
Reason Stopped
Drug/Alcohol Assessment
Which substances
Method of
Amount
Frequency
Time
Which substances
are currently used
use (
of use
of use
period
have been used in
oral,
inhalation,
(times/
of
the past
intranasal,
month)
use
)
injection
__ Alcohol
__ Alcohol
__ Caffeine
__ Caffeine
__ Nicotine
__ Nicotine
__ Heroin
__ Heroin
__ Opiates
__ Opiates
__ Marijuana
__ Marijuana
__
__
Cocaine/Crack
Cocaine/Crack
__
__
Methamphetamines
Methamphetamines
__ Inhalants
__ Inhalants
__ Stimulants
__ Stimulants
__ Hallucinogens
__ Hallucinogens
__ Other:
__ Other:
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