Chemical Dependency Evaluation Interview Form (Page 5 of 7) in pdf

Chemical Dependency Evaluation Interview Form Page 5

Have you ever been unable to remember part or all of what happened during a drinking or drug

use episode:

If yes, how many times would you estimate it happening and when was the most

recent occurrence:

Have you ever been to a hospital, treatment center, or counseling session because of drinking or

drug use:

If yes:

When?

Where?

Duration of treatment?

How long were you abstinent from drugs/alcohol following this?

What even triggered a relapse:

Have you ever attended AA/NA?

When?

Have you ever drank alcohol or used drugs

1) before going to work:

2) during work:

3) suffered a hangover at work:

Has a physician ever suggested that you slow down or stop drinking or using drugs:

Have you ever been diagnosed as having hepatitis, liver problems, pancreatitis, or been treated

for any other physical condition that could be related to drinking/using:

Have you ever overdosed on alcohol or drugs:

If so, when:

Have you ever experienced shakes during the day or two following a night of drinking or drug use:

Do you ever find yourself shaking at any time:

Have you ever experienced seizures:

If yes, how often:

Have you ever been treated for seizures?

Do you think your drug or alcohol use has gotten out of control:

Has it resulted in hospitalization or jail time: (Please specify)

Chemical Dependency Evaluation Interview Form Page 5