| Acquired harms |
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How is your health in general? Excellent ___ Very Good ___ Good ___ Fair ___ Poor ___ ________________________________ What doctors do you currently see? ________________________________ How often do you see your doctor? ________________________________ Do you have any physical or medical problems? ________________________________ YES ____ NO ____ If so, what? ________________________________________________________________ ______________________________________________________________________________ Is there anything that makes it better? ________________________________ Is there anything that makes it worse? ________________________________ Do you find it difficult to accomplish daily tasks like vacuuming, driving or cooking? ________________________________ YES ____ NO ____ Does your health keep you from doing the things you want to do? ________________________________ YES ____ NO ____ Have you ever been treated by a psychiatrist or counselor? ________________________________ YES ____ NO ____ If so, do you feel it helped you? How has your mood been? ________________________________ Have you felt very sad or down in the past three months? ________________________________ YES ____ NO ____ A. Excited or hyper? YES ____ NO ____ B. Anxious or afraid? How many hours a night do you sleep? ________________________________ A. Is that normal for you? YES ____ NO ____ How many hours a day do you sleep? ________________________________ A. Is that normal for you? YES ____ NO ____ How are your eating habits? ________________________________ A. Is that normal for you? YES ____ NO ____ Have you been very nervous or worrying a lot? YES ____ NO ____ ________________________________ What do you worry about? ________________________________ Are there some choices you’ve made in your life that turned out to make things harder for yourself or your family? ________________________________ YES ____ NO ____ A. If so, explain __________________________________________________________ Have you felt troubled or irritable lately? ________________________________ YES ____ NO ____ How long has this been a problem? ________________________________ Has this ever been a problem in the past? ________________________________ YES ____ NO ____ What helped the problem? ________________________________ Please tell me what medications you take? ________________________________ Do you take any over the counter medication? ________________________________ YES ____ NO ____ A. If yes, what? ________________________________ Do you take any vitamins or supplements? YES ____ NO ____ A. If yes, what? __________________________________________________________ Do you have any problems with your teeth? ________________________________ YES ____ NO ____ How often do you go to the Dentist? ________________________________ Have you had surgery in the past? ________________________________ YES ____ NO ____ A. If yes, for what and when did it occur? ____________________________________ _____________________________________________ ________________________________ Children How many live births have you given up to today? ________________________________ How many still births have you given up to today? ________________________________ How many miscarriages, abortions, dilatation and curettage have you gone through up to today? ________________________________ How is your child/children’s health? ________________________________ Does your child/children take any medications? YES ____ NO ____ A. If yes, for what? ______________________________________________________ __________________________________________________ How often do you take your child/children to the doctor? ________________________________ Medication How often? Who prescribed? For what? ________________________________ Do you have any family responsibilities or problems that are keeping you from making changes or improvements that would make your life better? ________________________________ YES ____ NO ____ A. If yes, please describe Have you or anyone in your household ever been arrested or been involved with the police? ________________________________ YES ____ NO ____ A. If yes, please explain What services have you received from other offices, organizations or agencies within the last two years? ________________________________ A. Please list Agencies and Services received __________________________________ ______________________________________________________________________________ B. What helped and what didn’t? ______________________________________________ ______________________________________________________________________________ C. For those that didn’t help, please explain why you think they didn’t help SUBSTANCE ABUSE How often do you currently drink beer, wine, or liquor? ________________________________ Never 1-2 times weekly Once a month 3-4 times weekly Twice a month Everyday Other How much beer, wine, or liquor do you usually drink at one time? ________________________________ Don’t drink 4-5 drinks One drink only 6 drinks or more 2-3 drinks In the past year, for which of the following reasons have you drank alcohol or used drugs? ________________________________ To get high To escape problems To relax To socialize To have fun To fit in with the crowd Do you think that you use too much drugs or alcohol? ________________________________ YES ____ NO ____ Have you ever felt the need to quit or cut down on your drug or alcohol use? ________________________________ YES ____ NO ____ Has anyone ever expressed concern about your drug or alcohol use? ________________________________ YES ____ NO ____ Have you felt badly or guilty about your drug or alcohol use? ________________________________ YES ____ NO ____ Do you ever take a drink or a drug in the morning to feel better? ________________________________ YES ____ NO ____ Has your drug or alcohol use caused family, job, or legal problems? ________________________________ YES ____ NO ____ Do you get angry or lose your temper when using drugs or alcohol? ________________________________ YES ____ NO ____ Do you use more drugs or alcohol to get the effect you want? ________________________________ Do you think you have a drug or alcohol problem now? ________________________________ YES ____ NO ____ Do any family members have a drug or alcohol problem? ________________________________ YES ____ NO ____ May I refer you to someone that can get you help? ________________________________ (Education, Self-Help, Treatment) Are you able to get public transportation? ________________________________ GOAL PLANNING What job would you like to try if you could? ________________________________ Do you have family and/or friends who can help you in meeting your goal? ________________________________ YES ____ NO ____ A. If yes, please tell us whom? ________________________________________________ Do you have any problems finding child care? ________________________________ YES ____ NO ____ A. If yes, please explain ______________________________________________________ ___ List three or more things that you like about yourself and/or that you do well. 1. ________________________________________________________________________ 2. ________________________________________________________________________ 3. ________________________________________________________________________ 4. ________________________________________________________________________ What do you want to be doing in two years? ________________________________ What do you think you need to get there? ________________________________ What do you want to get out of this program? ________________________________ How would you like to change or make your life better? ________________________________ What is keeping you from making those changes? ________________________________ How can we help you make the changes you would like to make to better your life? ________________________________ Do you have any other Comments/Information you would like to share with us? ________________________________ If so, please do so. __________________________________________________________ ______________________________________________________________________________ |