Chemical Dependency Evaluation
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1Chemical Dependency Evaluation
Personal Information
Name:
Date:
Address:
Phone:
Email:
DOB:
Sex:
Substance
What is/are your substance(s) of choice?
Amount Per Use:
Frequency of Use:
Age of First Use:
Date of Last Use:
Have you had any legal, work or home issues caused by substance use?
If yes, please describe:
Have you ever been formally diagnosed or treated for substance abuse?
Substance:
Dates of Treatment:
Doctor:
Location:
Family history of abuse?
Who?
What substance(s)?
General Symptoms of CD (Check All That Apply)
Daily Use
Morning Drinking
Binging
Black Outs
Loss of Control
Increased Tolerance
Hiding Supply
Guilt
Sneaking Use
Use as a reward
Use to reduce stress
Unable to quit
Pre-drinking
Preoccupation
Symptoms of Withdrawal (Check All That Apply)
Tremors
Delirium
Seizures
High Blood Pressure
Ulcers
Gastritis
Hepatitis
Nosebleeds
Behavioral Changes (Check All That Apply)
Increased Anger
Emotional Abuse
Physical Abuse
Verbal Abuse
Isolation
Depression
Stress
Anxiety
Sexual Increase
Sexual Decrease
More Social
Less Social
Insomnia
More Relaxed
Embarrassed by Use
Broken Promises
Family Worried
Friends Worried
Coworkers Worried
Symptoms of Withdrawal (Check All That Apply)
Tremors
Delirium
Seizures
High Blood Pressure
Ulcers
Gastritis
Hepatitis
Nosebleeds
Biomedical Conditions and Complications
High/Low Blood Pressure
Y
N
High/Low Blood Sugar
Y
N
Rheumatic/Scarlet Fever
Y
N
Chest Pains
Y
N
Fainting Spells
Y
N
Kidney Disease/Bladder Infection
Y
N
Cancer, Type:
Y
N
Diabetes
Y
N
Epilepsy
Y
N
Anemia/Blood Disorder
Y
N
Heart Trouble
Y
N
Pregnancy
Y
N
Signature
Date
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