JWFC Adult History Questionnaire- Substance Use

Jordan West Family Counseling

Adult History Questionnaire- Substance Use
Court Orders Clients
Name:*
Date of Birth*

MonthDayYear
Date
AGE:*
Case #
Referred by:
Court:
Charge:

Do you have a primary physician?*

YesNo
What is their name?
Do you have any other physicians who are currently treating you?*

YesNo
What is their name?
What year did you have your last examination by a physician?

Do you have any allergies to the environments?*

YesNo
List Environmental Allergies:
Do you have any allergies to medications?*

YesNo
List and identify the type of reactions that you experienced (such as hives, etc.)

Are you currently taking any medications?*

YesNo
Please list any medications you are taking:
Are you taking the medication as prescribed by your physician?*

YesNoN/A
Are you taking any vitamins or supplements?*

YesNo
Please list any supplements and dosages:

Do you have any current health concerns?*

YesNo
Please List:
Have you ever, during your life, had any significant health concerns?*

YesNo
Please List:
Have you ever been hospitalization(s) or visit(s)?*

YesNo

Do you have a current dentist?*

YesI don’t have a dentist
What is the name of your current dentist?
Have you ever had any dental problems?*

YesNo
In what year did you last have dental work?

	Number of ...
Days?
Weeks?
Months?
Years?

Please, answer the following questions about your employment history for the past 10 years:

EmployerLength of employment Reason for leaving
Employment history for the past 10 years continued:

EmployerLength of employment Reason for leaving
Employment history for the past 10 years continued:

EmployerLength of employment Reason for leaving
Employment history for the past 10 years continued:

EmployerLength of employment Reason for leaving

Is someone requiring that you complete this assessment? Check all that apply>

Partner/SpouseType EmployerLegalOther

Living arrangements:

I live aloneType I live with someone 2I rentI am purchasing my residenceI own my residenceOther

I have provided the following documents to assist in the development of this assessment:*

Police ReportSubstance Abuse screeningMental Health EvaluationBCI (criminal History)Victim Report/Impact StatementCPD/DCFS RecordsPrison RecordPre-sentence ReportProbation Information Report
File Upload For Assessment Documents:

Cancelof
I have completed this questionnaire and I verify that my answers are accurate.
Client Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

	1	2	3	4	5	6	7
Alcohol
Marijuana
Nicotine
Caffeine
Vape
LSD
Mushrooms
Metham-phetamine
Cocaine
Opiates
Club Drugs
Steroids
Other:

	1	2	3	4	5	6	7
Alcohol
Marijuana
Nicotine
Caffeine
Vape
LSD
Mushrooms
Metham-phetamine
Cocaine
Opiates
Club Drugs
Steroids
Other:

	1	2	3	4	5	6	7
Alcohol
Marijuana
Nicotine
Caffeine
Vape
LSD
Mushrooms
Metham-phetamine
Cocaine
Opiates
Club Drugs
Steroids
Other:

	Yes	No
Have you ever spent most of a day using drugs?
Does it now take more alcohol or drugs to get the same effect as it once did?
Have you ever wanted to stop drinking or using drugs but could not?
Have you ever used drugs or alcohol to reduce or avoid withdrawal?
Have you ever had seizures after drug or alcohol use?
Have you ever had tremors after drug or alcohol use?
Have you ever experienced anxiety after drug or alcohol use?
Have you ever experienced night or day sweats after drug or alcohol use?
Have you ever experienced sleep disturbance after drug or alcohol use?
Have you ever experienced nausea or vomiting after drug or alcohol use?
Have you ever experienced hallucinations after drug or alcohol use?
Have you ever experienced vivid, unpleasant dreams after drug or alcohol use?
Have you ever experienced restlessness or nervousness after drug or alcohol use?
Have you ever been angry, irritable or frustrated after drug or alcohol use?
Have you ever become hostile or violent while using drugs or alcohol?
Have you ever skipped eating because of drug or alcohol use?
Have you ever continued to use drugs or alcohol longer than you planned?
Has the desire to use drugs or alcohol ever been so strong that you could not resist using?
Have you ever felt that your life revolved around your drug or alcohol use?
Have you ever spent most of a day recovering from alcohol or drug effects?
Have you ever had difficult performing your job or school duties because of drug or alcohol use?
Have you ever found yourself preoccupied with wanting to use drugs or alcohol?
Have you ever used alcohol or drugs when you felt sad, anger, or bored?
Have you every changed recreational activities to be with people who use?
Have you ever had medical problems that someone else believed were due to drug or alcohol use?
Have you ever used drugs or alcohol despite knowing that the use may negatively affect your health?

	0	1	2	3
Sleep Disturbance
Appetite Disturbance
Episodic Crying
Low Energy
Depressed Mood
Poor Concentration
Stress/anxiety/worry
Panic Attacks
Memory Loss
Obsessions/Compulsions
Phobias
Mood swings
Irritability
Aggressive Behavior
Homicidal thoughts
Suicidal Ideation
Cut or hurt self
Sexual problems
Physical Pain
Grieving
Substance Abuse
eating Disorder
Co-worker conflict
Relationship conflict
Work/Career Indecision
Academic Problems
Other

	Treatment Program Name	Mandated?	Date completed	Amount of Time abstinent
1
2
3

Jordan West Family Counseling