Optional Health Assessment Modules Form Page 24
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27UR Number:
Surname:
Given name:
Date of birth:
(Please fill in if no label available)
RELATIONSHIP – PAST 30 DAYS
HOW OFTEN HAVE YOU
HOW BOTHERED WERE YOU BY THE
EXPERIENCED THE PROBLEM?
PROBLEM?
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11. You had arguments with your loved one
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4
12. Your loved one verbally abused you
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13. You did things for your loved one that you think (s)he should have
done for himself/herself
14. You spent a lot of time thinking about how to help your loved one
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with his/her problem
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4
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15. You gave up doing things that you wanted to do because of your
loved one’s problem
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4
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4
16. You were disturbed because your loved one came home later than
expected
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17. You felt distant from your loved one
FAMILY – PAST 30 DAYS
HOW OFTEN HAVE YOU
HOW BOTHERED WERE YOU BY THE
EXPERIENCED THE PROBLEM?
PROBLEM?
18. Your family members had arguments with your loved one
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4
0
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4
19. Your family members argued with each other about your loved one
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4
0
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4
20. Your loved one disrupted a family gathering
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4
0
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4
21. Your relationship with your loved one interfered with relationships
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4
0
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with other family members or friends
22. You did not have enough time with friends
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4
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4
23. You did not enjoy time with family members
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24. You saw your loved one or his/her friends using alcohol in your
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4
0
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home
25. You saw your loved one or his/her friends using drugs in your home
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4
0
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4
26. You found alcohol in your home
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4
0
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4
27. You found drugs in your home
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0
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4
28. You argued with your loved one about alcohol or drug use in your
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4
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home
29. You argued with your loved one about drug paraphernalia in your
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4
0
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home
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
23
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