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  • Evaluation Prac Court

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    jems
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    This document contains an evaluation of a client's substance use history. It collects information on first use, pattern of use over time, frequency of use in the last month, and most recent use for various categories of drugs including alcohol, caffeine, marijuana, stimulants, sedatives, opiates, steroids, hallucinogens, and tobacco. It also notes the client's reason for seeking the evaluation and allows space for the physician's notes. The goal is to comprehensively document the client's substance use for treatment purposes.

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    Evaluation Prac court

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    This document contains an evaluation of a client's substance use history. It collects information on first use, pattern of use over time, frequency of use in the last month, and most recent use for various categories of drugs including alcohol, caffeine, marijuana, stimulants, sedatives, opiates, steroids, hallucinogens, and tobacco. It also notes the client's reason for seeking the evaluation and allows space for the physician's notes. The goal is to comprehensively document the client's substance use for treatment purposes.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    8 views2 pages

    Evaluation Prac Court

    Uploaded by

    jems
    This document contains an evaluation of a client's substance use history. It collects information on first use, pattern of use over time, frequency of use in the last month, and most recent use for various categories of drugs including alcohol, caffeine, marijuana, stimulants, sedatives, opiates, steroids, hallucinogens, and tobacco. It also notes the client's reason for seeking the evaluation and allows space for the physician's notes. The goal is to comprehensively document the client's substance use for treatment purposes.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    Evaluation on Client’s Substance Use

    Client’s Name____________________________________________________________

    Date and circumstances of Evaluation________________________________________

    a. Client’s Reason for Seeking Evaluation_____________________________________


    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________

    b. Substance Use History (Note: AOD is an acronym for Alcohol and Other Drugs)

    Category of Drugs First use? Pattern of use Frequency of Date amount of


    over time use in the last most recent
    month use
    Alcohol

    Caffeine

    Marijuana

    CNS
    Stimulants or “Uppers”
    e.g. Cocaine, Ritalin
    Methamphetamine

    Anxiolytics/Sedatives/Hypnotics
    or “Downers”
    Barbituates
    Secobarbital/ Quaaludes
    Benzodiazepines
    Valium (diazepam)
    Xanax (alprazolam)
    Rohypnol
    Opiates or “Painkillers”
    Heroin/Morphine/
    Methadone/Oxycodone
    Steroids

    Cigarettes/Nicotine/Tobacco
    Hallucinogens
    LSD/PCP/Ecstasy

    Have you ever used any of these drugs in combination?

    _____________________________________________________________________________________________
    _______________________________________________________________________.

    Physician’snotes
    _____________________________________________________________________________________________
    _____________________________________________________________________________________________
    _____________________________________________________________________________________________
    _____________________________________________________________________________________________
    _____________________________________________________________________________________________
    _____________________________________________________________________________________________
    _____________________________________________________________________________________________
    _.

    Dr. Jemimah Ribon

    Attending Physician

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