Hiawatha Valley Substance Abuse History Form Page 4
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6NICOTINE
OTHER
Do you use greater amounts of alcohol/other drugs to feel intoxicated or achieve the desired effect? Or use the same amount
and get less of an effect?
Yes
No
Have you ever been to
When was the first time?
How many times since
Date of most recent detox?
detox?
Yes
No
then?
Withdrawal symptoms; Have you had any of the following withdrawal symptoms?:
Past 12
Recent
Symptom
Past 12
Recent
Symptom
months
(past 30 days)
months
(past 30 days)
SWEATING (RAPID PULSE)
NAUSEA/VOMITING
SHAKY/JITTERY/TREMORS
DIZZINES
UNABLE TO SLEEP
SEIZURES
AGITATION
DIARRHEA
HEADACHE
DIMINISHED APPETITE
FATIGUE/EXTREMELY TIRED
HALLUCINATIONS
SAD/DEPRESSED FEELING
FEVER
MUSCLE ACHES
UNABLE TO EAT
VIVID/UNPLEASANT
PSYCHOSIS
DREAMS
CONFUSED/DISRUPTED
IRRITABILITY
SPEECH
SENSITIVITY TO NOISE
ANXIETY/WORRIED
HIGH BLOOD PRESSURE
Are you seriously considering addressing your alcohol and/or drug use within the next six months?
Yes
No
Are you planning to stop or reduce your alcohol and/or drug use in the next 30 days?
Yes
No
(Perhaps taking small steps to do so)?
Are you now actively remaining abstinent from your use of alcohol and/or drugs?
Yes
No
Have you ever felt you ought to cut down on your drinking or drug use?
Yes
No
Have you ever had people annoy you by criticizing your drinking or drug use?
Yes
No
Have you ever felt bad or guilty about your drinking or drug use?
Yes
No
Have you ever had a drink or used drugs as an eye opener first thing in the morning
Yes
No
to steady your nerves, to get rid of a hangover, or to get the day started?
Reasons for drinking/drug use (Check answers that apply)
Like the feeling
To relax or unwind
Partner encourages use
Trying to forget problems
Makes it easier to talk with people
Most friends drink or use
To cope with stress
To cope with family problems
To cope with family problems
To relieve physical pain
To cope with anxiety
To cope with depression
Other (specify)
Have you ever been to an AA/NA or
Yes
No If yes, date of last meeting ____________________________
any other 12-Step Support Group?
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Parent category: Medical