Optional Health Assessment Modules Form Page 23
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27OPTIONAL MODULE 11:
UR Number:
IMPACT OF AOD USE
Surname:
Given name:
ON FAMILY MEMBER
Date of birth:
(Significant Other Survey)
(Please fill in if no label available)
PURPOSE OF MODULE
INTRODUCTION FOR CLIENT
To explore the impact of a loved one’s
“Now I’m going to ask you about a number of difficulties that are sometimes reported by people with a
AOD use on a family member.
loved one who may have an alcohol or other drug problem. I’m going to ask you to think about the past 30
days and indicate how often you may have experienced a particular difficulty (if at all), and how much the
problem has bothered you in the past 30 days.”
WHO CAN ADMINISTER THIS MODULE?
This module can either be
INSTRUCTIONS
self-completed by the client or
1. Complete both sets of columns. If a client indicates that they have never experienced a particular
administered by the clinician.
problem in the past 30 days, then the they/you would circle 0 (Not at all) in the next column, which
relates to how bothered they have been by the problem in the past 30 days.
2. Once completed, identify problems/difficulties that occur frequently and/or that the client is particularly
bothered by.
3. Use this information gathered to inform care planning, and to make referrals to family support services/
groups as required. Consider completing Optional Module 10: Family Violence if violence is reported.
4. Consider re–administering the module at a minimum of 30 days after first completed to monitor
changes in the frequency of particular problems and how bothered the client is by these over time.
EMOTIONAL – PAST 30 DAYS
HOW OFTEN HAVE YOU
HOW BOTHERED WERE YOU BY THE
EXPERIENCED THE PROBLEM?
PROBLEM?
1. You had trouble sleeping
0
1
2
3
4
0
1
2
3
4
2. You had trouble eating (eating more or less than usual or having
0
1
2
3
4
0
1
2
3
4
no appetite)
3. You felt guilty
0
1
2
3
4
0
1
2
3
4
4. You felt embarrassed
0
1
2
3
4
0
1
2
3
4
5. You felt angry
0
1
2
3
4
0
1
2
3
4
6. You felt anxious or worried
0
1
2
3
4
0
1
2
3
4
7. You felt sad or depressed
0
1
2
3
4
0
1
2
3
4
8. You felt hopeless
0
1
2
3
4
0
1
2
3
4
9. You had trouble concentrating
0
1
2
3
4
0
1
2
3
4
10. You felt you had too much responsibility for the welfare of family,
0
1
2
3
4
0
1
2
3
4
friends and/or yourself
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
22
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