Intake Assessment Client Name: Date of Birth: Admit Date / Time: Insurance Name: DRUG OF CHOICE: - Alcohol Last Used (date/time): Amount Used (Quantity) Frequency (how often) DURATION (how long) DRUG OF CHOICE: - Opiates Last Used (date/time): Amount Used (Quantity) Frequency (how often) DURATION (how long) DRUG OF CHOICE: - Methamphetamine Last Used (date/time): Amount Used (Quantity) Frequency (how often) DURATION (how long) DRUG OF CHOICE: - Benzodiazepine Last Used (date/time): Amount Used (Quantity) Frequency (how often) DURATION (how long) DRUG OF CHOICE: - Cannabis Last Used (date/time): Amount Used (Quantity) Frequency (how often) DURATION (how long) DRUG OF CHOICE: - Cocaine Last Used (date/time): Amount Used (Quantity) Frequency (how often) DURATION (how long) DRUG OF CHOICE: - Others Last Used (date/time): Amount Used (Quantity) Frequency (how often) DURATION (how long) VITALS - BP: / P: RR: TEMP: BAL: CIWA Score: COWS Score: Hx of Seizure: YN, last episode? Hx of head injuries: YN, when? Hx of DT: YN when? Suicidal or Homicidal Thoughts? YN Hx of 5150: YN when? ROS N/VDiarrheaConstipationFeverSOBBody AcheHAChest painAnxietyRunning nosePatient denies any nausea, vomiting, diarrhea, chest pain, shortness of breath, abdominal pain, headache, fever. chills, body ache How many times in rehab? when was the last rehab? How long did you stay sober? When did you relapse? Medical Problems: HTNDiabetesDyslipidemiaStrokeAsthmaCOPDh/o TuberculosisOthers History of Surgery: Gastric bypassAppendectomyHysterectomyC-sectionHeart surgeryPacemaker History of Mental Health: AnxietyDepressionBipolarSchizophreniaPTSDADHDOthers Insomnia: YN, do you take any sleep aid: YN Hours Sleep? SMOKER: YN, how long have you been smoking?: History of Asthma: YN Hx of COPD: YN Hx of Tuberculosis: YN Allergies: NKDAOthers Medications Lists: Living situation: AloneWith FriendsWith FamilyHomelessOthers Does anyone drink or use drugs at home? YN If yes, Who? Family History of Alcohol and drug abuse? YN If yes, Who? Marital Status: SingleMarriedSeparatedDivorcedDomestic PartnerOthers Highest Level of Education: High SchoolCollegeTrade SchoolOthers Employed: YN How long at this job? if NO, Last time you are employed? Disability: YN If Yes, Why? Current /Past legal Issues: YN DUI: YN Staff Name: Staff Signature : Next No of days of detox - Date - Patient Name DOB How is your detox coming along? Vital signs: BP Pulse RR Temp ROS N/VDiarrheaConstipationFeverSOBBody AcheHAChest painAnxietyRunning nosePatient denies any nausea, vomiting, diarrhea, chest pain, shortness of breath, abdominal pain, headache, fever. chills, body ache Cravings? YN On Scale12345678910 What can we do? Anger/Agitation/Hallucination?YN12345678910 What can we do? Anxiety? YN On Scale 12345678910 What can we do? Depression? YN On Scale 12345678910 What can we do? Any Homicidal and Suicidal thoughts YN If yes, Passive thoughtHave a plan Do you need to talk to counselor or Provider YN How is your Sleep GoodFairPoor No of hours sleep Other concerns PreviousNext PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9) 1. Little interest or pleasure in doing things 0123 2. Feeling down, depressed, or hopeless 0123 3. Trouble falling or staying asleep, or sleeping too much 0123 4. Feeling tired or having little energy 0123 5. Poor appetite or overeating 0123 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0123 7. Trouble concentrating on things 0123 , such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0123 9. Thoughts that you would be better off dead or of hurting yourself in some way 0123 Back
