In the following self-assessment, please answer the questions honestly either yes or no;
Drug of choice? (please select, required) Not applicableAlcoholBenzodiazepineCannabisCocaineHeroinMethadoneSubutexAmphetaminesIce/Crystal MethPrescription Medication
Is your using or drinking increasing in amount? YesNo
Have you felt decrease in effect? YesNo
Have you ever felt any withdrawal symptoms or shakes? YesNo
Ever taken in larger amounts and for longer periods than intended? YesNo
Any repeated unsuccessful attempt to quit? YesNo
In the past have you been in trouble at school, work or with the law as a result of drinking or drug use? YesNo
In the past year has your drug use or drinking caused problems at home with your family, children, parents or spouse? YesNo
Use continues despite knowledge of adverse consequences or against professional advice? YesNo
When drinking with other people, do you try to have a few extra drinks when others won’t know about it? YesNo
Do you use or drink alone? YesNo
Do you sometimes feel a little guilty about your drinking or using? YesNo
Has a family member or close friend express concern or complained about your using/drinking? YesNo
Have you been having more memory “blackouts” recently? YesNo
Do you usually have a reason for the occasions when you use/drink heavily? YesNo
When you’re sober, do you sometimes regret things you did or said while using/drinking? YesNo
Have you sometimes failed to keep promises you made to yourself about controlling or cutting down? YesNo
Do you try to avoid family or close friends while you are using/drinking? YesNo
Have you ever gone to anyone for help? YesNo
Have you experienced any seizures? YesNo
Detox required? YesNo
Your details:
Your Name (required)
Your Gender ---MaleFemale
Your Age (required)
Your Nationality (required)
Your Email (required)
Your Telephone Number (required)
Medical issues?
Personal issues?
Health issues?
Mental health diagnosis?
History of suicide?
Are you on any prescription medication?
Any other information?
