Dararehab : Pre-Assessment Form

PERSONAL DETAILS

Today's Date

Surname

First Name

Passport Number

Issued date

Nationality

Expired Date

Gender

Male

Female

Date of Birth

Contact Address

Contact Number

Contact email

Country

Postcode

Emergency Contact Person

Relationship

Contact Number

Contact email

GENERAL INFORMATION

How did you learn about DARA?

The primary language used at the center is English. Do you have a problem with understanding, reading or writing the English language?

Yes

What is your preferred length of residential stay?

4 Weeks

8 Weeks

12 Weeks

What was the crisis or precipitating event for entering treatment?

Who initiated treatment?

What do you want help with?

How motivated are you to change your drinking or drug use?

Low

Medium

High

PATTERN/FREQUENCY/AMOUNT OF SUBSTANCES USED

Substance	First Use (Age)	Method of Use	Current Use	How Much (Vol/Weight)
Alcohol
Cocaine / Crack
Heroin
Methamphetamine
Amphetamine (Ritalin / Benzedrine / Adderal / Dexedrine)
Designer Drugs Ecstasy / MDMA/GBH
Tranquilizers/Benzos Valium / Xanax / Klonopin / Librium / Ambien / Temazepam / Halcion
Other Opiates Hydrocodone / Oxycodone / Oxycontin / Morphine / Codeine / Methadone / Dilaudid / Fentanyl
Marijuana
Hallucinogens (LSD / Mushrooms / PCP / Mescaline)
Inhalants Aerosols / Gases / Solvents / Glue
Ketamine
Others

How long have you been using your particular drug of choice or alcohol above and when did you last use?

Have you used or drank in the last week?

Yes

Is it likely you will have used or drank 5 days before coming to treatment?

Yes

When you use or drink have you experienced (please tick)

Loss of Memory

Passing Out

Domestic Violence

Being Verbally Abusive

A Drink / Drug Driving Offence

Homicidal Thoughts

ABSTINENCE AND WITHDRAWAL

What is the longest period of total abstinence that you have had in the past 5 years and why did you stop?

When you stop drinking or using do you get sick? If so, describe the symptoms:

How many times have you attempted to stop or control your drinking or using?

Have you ever participated in any kind of drug or alcohol rehabilitation program before? (Please give details of how many times, when, where, how long, and any detox complications.)

Month/Year	Facility Name	Level of Care	How Long	Complications

Do you think you will need detox?

CURRENT MEDICATIONS

Any drug allergies? If yes, please specify:

Yes

Details of medications currently being used, both prescribed and over the counter:

REFERRING DOCTOR

Primary Physician that prescribed current medication:

Surname

First Name

Phone Number

Psychiatrist that prescribed current medication:

Surname

First Name

Phone Number

Are you comfortable with us contacting your doctors after your admission if it becomes necessary?

Yes

Dietary requirements. Do you have any food allergies or any foods you do not eat?

What obstacles might prevent you from coming into treatment?

Any other information you feel might be helpful to us!

DARA - Thailand By Asia Health Co., Ltd.

CLIENT ASSESSMENT FORM

PERSONAL DETAILS

GENERAL INFORMATION

PATTERN/FREQUENCY/AMOUNT OF SUBSTANCES USED

ABSTINENCE AND WITHDRAWAL

MEDICAL HISTORY

PSYCHIATRIC HISTORY

CURRENT MEDICATIONS

REFERRING DOCTOR

THANK YOU