Phone

(###)

###

####

Court Date

MM

DD

YYYY

Last Court Date

MM

DD

YYYY

Next Court Date

MM

DD

YYYY

Have you been sick in last 7 days?

Yes

No

Have you been recently injured or being treated for an injury

Yes

No

Date of last physical exam

MM

DD

YYYY

Are you under a physician’s care for a particular problem?

Yes

No

Have you ever had any serious illnesses, operations or hospitalizations?

Yes

No

Congenital Heart Disease

Yes

No

Cardiovascular Disease

i.e. Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker

Yes

No

Lung Disease

i.e. Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing

Yes

No

Seizures, Convulsions, Epilepsy, Fainting or Dizziness

Yes

No

Bleeding Disorder, Anemia, Bleeding Tendency

Yes

No

Liver Disease

i.e. Jaundice, Hepatitis

Yes

No

Kidney Disease

Yes

No

Digestive Problems

i.e. Ulcerative Colitis, Crohn’s Disease, Acid Reflux, Ulcers, Irritable Bowel

Yes

No

Diabetes

Yes

No

Thyroid Disease

Yes

No

Arthritis

Yes

No

Eye Problems

Yes

No

Dental Problems

Yes

No

Ear, Nose and Throat Problems

i.e. Difficulty Hearing, Ear Ringing, Dizziness, Sinus Problems, Sleep Apnea

Yes

No

Any Communicable Disease

i.e. Scabies, Head or Body Lice, Impetigo, Shingles, Herpes, Venereal Disease

Yes

No

Any Disease, Drug or Transplant that has depressed your immunity

Yes

No

Any history of Mental Illness or Psychotic Episodes

Yes

No

Are you currently suffering from depression?

Yes

No

Do you have thoughts of harming yourself or others?

Yes

No

Do you have any plans to hurt yourself or others?

Yes

No

Do you feel you are a normal drinker?

"normal"=drink as much or less than most other people

Yes

No

Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?

Yes

No

Do your friends or family ever worry or complain about your drinking?

Yes

No

Can you stop drinking without a struggle after one or two drinks?

Yes

No

Do you ever feel bad about your drinking?

Yes

No

Do your friends or relatives think you are a normal drinker?

Yes

No

Do you ever try to limit your drinking to certain times of the day or to certain places?

Yes

No

Are you always able to stop drinking when you want to?

Yes

No

Have you ever attended a meeting of Alcoholics Anonymous (AA) or any other group concerned about drinking?

Yes

No

Have you ever gotten into fights when drinking?

Yes

No

Has your drinking ever created problems with you and your friends or family?

Yes

No

Has any family member or close friend gone to anyone for help about your drinking?

Yes

No

Have you ever lost a job or been suspended from school because of your drinking?

Yes

No

Have you ever gotten into trouble at work / school because of your drinking?

Yes

No

Have you ever lost friends because of your drinking?

Yes

No

Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?

Yes

No

Do you drink before noon?

Yes

No

Have you ever been told you have liver trouble?

Yes

No

Have you ever had delirium tremens (DTs), severe shaking, heard voices, or seen things that were not there after heavy drinking?

Yes

No

Have you ever gone to anyone for help about your drinking?

Yes

No

Have you ever been to a hospital or emergency room because of your drinking?

Yes

No

Have you ever been a patient in a psychiatric hospital or a psychiatric ward in a general hospital, where drinking was part of the problem?

Yes

No

Have you ever been to a mental health clinic, gone to a doctor, social worker, counselor, or clergyman for help with an emotional problem in which drinking played a part?

Yes

No

Have you ever been arrested, even for a few hours, because of drunk behavior?

Yes

No

Have you ever been arrested for drunk driving or driving after drinking?

Yes

No

Which recreational drugs have you used in the past 12 months?

Methamphetamines (speed, crystal)

Cannabis (marijuana, hash)

Inhalants (paint thinner, aerosol, glue, etc.)

Tranquilizers (valium)

Cocaine (crack)

Narcotics (heroin, hydrocodone, oxytocin etc.)

Other (use text box below to answer)

Have you used drugs other than those required for medical reasons?

Yes

No

Do you abuse more than one drug at a time?

Yes

No

Are you always able to stop using drugs when you want to?

If never use drugs, answer “yes”

Yes

No

Have you had “blackouts” or “flashbacks” as a result of drug use?

Yes

No

Do you ever feel bad or guilty about your drug use?

If never use drugs, choose “no.”

Yes

No

Does your spouse (or parent) ever complain about your involvement with drugs?

Yes

No

Have you neglected your family because of your use of drugs?

Yes

No

Have you engaged in illegal activities in order to obtain drugs?

Yes

No

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?

Yes

No

Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?

Yes

No