Scvhhs Annual Update - Department Of Alcohol And Drug Services
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1
2Annual Update
12/22/05
SCVHHS
Department of Alcohol and Drug Services
Number of Annual Updates _______
Admit Date _________________
AOD use during past 30 days: (See Code Sheet)
Last 30 Days
Amount/
Route of Adm
(# of Days)
Frequency
Substance/ Substance
(1.Oral 2.Smoking
Code
Name
3.Inhalation 4. Injection 5. Other)
Primary
______
______________
__________
_______
__________
Secondary
______
______________
__________
_______
__________
Tertiary
______
______________
__________
_______
__________
Other
______
______________
__________
_______
__________
(If Alcohol is not primary or secondary drug then ask next question)
How many days in the past 30 days have you used alcohol? ________days
(0-30) or 902: Not Applicable
Have many days have you injected drugs in the last 30 days? _________days
(0-30) or 900: Decline to State
What type of disability/disabilities do you have?
None
Visual
Hearing
Speech
Mobility
Mental
Developmental
Other (not AOD)
Declined to State
Unable to Answer
Are you a Medi-Cal Beneficiary?
Y
N
Were you pregnant at anytime during treatment?
Y
N
Not Sure/Don’t Know
Have you been tested for HIV/AIDS?
Y
N
Decline to State Note: Do not ask the results of the test.
Did you receive the results of the HIV/AIDS Test?
Y
N
Decline to State Note: Do not ask the results of the test.
How many days in the past 30 days have you experienced physical health problems? (Please include such problems as flu, colds, and
physical ailments related to drugs or alcohol such as cirrhosis of the liver or abscesses from needles) __________ (0-30) days
How many times have you visited the emergency room in the past 30 days for physical health problems? _________ (0-99) days
How many days in the last 30 days have you stayed overnight in a hospital for physical health problems? ___________ (0-30) days
Have you ever been diagnosed with a mental illness
Y
N
Not Sure/Don’t Know
How many times in the past 30 days have you received outpatient emergency services for mental health needs? ________times
(0-99)
How many days in the past 30 days have you stayed for more than 24 hours in a hospital or psychiatric facility for mental health
needs? ______________days (0-30)
In the past 30 days, have you taken
prescribed medication for mental health needs?
Y
N
How many days in the past 30 days have you lived with someone who uses alcohol and/or other drugs?
______
(0-30) or 900: Decline to State
How many days in the past 30 days have you participated in any social support recovery activities (such as 12-step meetings, other
self help meetings, religious/faith recovery meetings, meetings of an organization other than those listed above, interactions with
family members and/or friend for support of your recovery)? _____________(0-30) days.
How many children do you have aged 5 or younger? ______________children (0-30)
How many children do you have aged 17 or less (birth or adopted) whether they live with you or not? ____________children (0-30)
How many of your children are living with someone else because of a child protection court order? ____________children (0-30)
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