DYS Clinical Data Packet


**Please complete this form for the person who is receiving services**

Legal Name: Last Name at Birth: Preferred Name: Date of Birth:  

Gender Self-Identification:

If other, please describe:

Pronouns:

If other, please describe:  

 

DIMENSION 1: Acute Intoxication and/or Withdrawal Potential

1(A): Substance Use

Please indicate if you've used any of the following substances:

Depressants/Sedative-Hypnotics

If other, please describe:  

Stimulants

If other, please describe:  

Hallucinogens/Psychedelics

If other, please describe:  

Inhalants

1(B): Withdrawal

Check any of the following that you experienced after you stopped using alcohol or other drugs:

If other, please describe:  

Did this happen in the last year?

If yes, when?  

Are you interested in quitting tobacco or attending a Tobacco Cessation support group?

 

1(C): Substance Use Problems

  1. Have you or anyone else felt like you should cut down on your drinking or other substance use?
     
  2. In the last year, how important have alcohol and/or other drugs been in your life?
     
  3. In the last year, how troubled or bothered have you been by alcohol or other drug problems?
    Please explain:  
  4. Do you think you have an alcohol and/or drug abuse problem?
     
  5. Have you ever had an alcohol and/or drug abuse problem?
    If yes, when?  

1(D): Gambling

Have you ever felt the need to lie about your gambling?

 

Have you ever felt the need to bet more and more money?

 

 

DIMENSION 2: Biomedical History and Complications

2(A): Personal History

Please check any that apply:

A physical disability:

 

Appetite problems:

 

Cancer/Tumor:

 

Chest pain or pressure:

 

Chronic pain:

 

Diabetes:

 

Epilepsy:

 

Eye problems, blurred or worsening vision:

 

Fainting, dizziness, or light-headed feelings:

 

Gained or lost 10 lbs. recently:

 

Hearing problems:

 

Heart palpitations, irregular or racing heartbeat:

 

High blood pressure:

 

Kidney problems:

 

Liver problems:

 

Lung problems:

 

MRSA:

 

Other contagious health condition (e.g., lice, scabies):

 

Problems with memory or concentration:

 

Rheumatism/Arthritis:

 

Seizures or convulsions:

 

Sexual problems:

 

Shakiness or trembling:

 

Significant headaches:

 

Stroke:

 

Thyroid problems:

 

Traumatic brain injury (e.g., concussion, hit in head):

 

Unexplained bruises or sores that don't heal:

 

Other:

 

Please list all medications you are currently taking or have taken in the last year, including non-prescription drugs, and the dosage of each, if known:

Are you under a doctor's care at this time?

When did you last see a doctor?  

Have you had a tetanus shot within the past 10 years?

 

Have you ever injected drugs?

If yes, when was the last time?  

Have you had any blood tests done since you last used?

 

Have you been incarcerated or in an inpatient substance abuse recovery program since you last used?

If yes, please explain:  

2(B): Family Medical and Psychiatric History

List serious medical conditions, past or current, of all close family members:

List mental health concerns for all close family members:

 

DIMENSION 3: Emotional, Behavioral, or Cognitive Conditions and Complications

What, if any, mental or emotional problems have you experienced in the past?

What, if any, mental or emotional problems are you currently experiencing?

Have you experienced any type of abuse?

Comments:  

Do you have a history of head trauma?

Comments:  

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling down, depressed or hopeless:

 

Little interest or pleasure in doing things:

 

Trouble falling asleep, staying asleep or sleeping too much:

 

Poor appetite or overeating:

 

Feeling tired or having little energy:

 

Feeling bad about yourself, or that you are a failure or have let yourself or your family down:

 

Trouble concentrating on things such as reading or watching television:

 

Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual:

 

Thoughts of that you would be better off dead, or of hurting yourself in some way:

In the past year have you felt depressed or sad most days, even if you felt okay sometimes?

If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?

Has there been a time in the past month when you have had serious thoughts about ending your life?

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

 

 

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious or on edge:

Not being able to stop or control worrying:

Worrying too much about different things:

Trouble relaxing:

Being so restless that it is hard to sit still:

Becoming easily annoyed or irritable:

Feeling afraid as if something awful might happen:

If you checked off any problems from this list, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

 

DIMENSION 4: Readiness to Change

Legal History

Have you ever been, or are you,  involved with the legal system?

If yes, when?  

 

DIMENSION 5: Relapse, Continued Use, or Continued Problem Potential

  1. Have you ever been in counseling/treatment? (detox, AOD rehab, outpatient mental health)
     
  2. What, if any, of the following are reasons you use/drink?

If other: please explain:  

 

DIMENSION 6: Recovery/Living Environment

6(A): Personal Habits and Lifestyle

Work: Hours/Day

Do you enjoy your work?

Comments:  

Do you participate in hobbies?

Comments:  

Exercise (type and how often):  

Amount and Type of caffeine per day:  

Describe any sleep concerns:  

6(B): Spiritual or Religious Beliefs and Practices

What are your religious/spiritual beliefs?  

6(C): Cultural Identification

How do you define yourself culturally?

6(D): Education

  1. Are you currently in school?
    If yes, name of current school:  
  2. School status:
     
  3. What is your learning style?
     
  4. Are you required to complete recovery services here in order to stay in school?
     
  5. Accomplishments (awards, merits, letters, trophies, honor roll, etc.):  
  6. Involvement in extracurricular activities (plays, sports, dances, etc.):  
  7. Has alcohol/drug use affected your school progress?
    If yes, please describe:  

6(E): Supports and Strengths

What drug-free support(s) do you have?

If other, please describe:  

How do you take care of yourself? 

6(F): Self-Help/Support Groups

What self-help groups do you currently attend or have you attended in the past?

If other, please describe:  

Frequency of self-help group attendance in the past 30 days:  

6(G): Family/Living Environment

Members in household:

Name: Age: Relationship to you:  

Name: Age: Relationship to you:  

Name: Age: Relationship to you:  

Name: Age: Relationship to you:  

Name: Age: Relationship to you:  

6(H): Strengths

What are your strenghts?

 

Infectious Disease Risk Assessment

**The following questions are necessary to assess your risk for infectious diseases. Please answer these questions. Confidentiality laws protect all answers.**

Infectious Disease Risk

Have you seen a health care provider in the past three months?

Do you or have you lived on the street or in a shelter?

Have you ever been in jail/prison/juvenile detention?

Have you ever been in a long-term care facility (mental health hospital, nursing home, rehab)?

In the past 3 months, have you traveled outside the US?

If yes, where?

Are you a combat veteran?

In the past year, have you had a tattoo, body piercing, acupuncture, or contact with blood?

Where were you born?

How long have you been in the US?

Have you lived with anyone diagnosed with TB in the past year?

Have you ever been treated for TB?

Have you ever been told you have Hepatitis A?

Have you ever been told you have Hepatitis B?

Have you ever been told you have Hepatitis C?

Have you ever used needles to shoot drugs?

Have you ever shared needles or syringes to inject drugs?

Have you ever had a job where you were at risk for needle sticks or blood contact?

In the past year, have you or anyone you had sex with had an STD or Hepatitis?

In the past 30 days, have you had any of these symptoms lasting more than 2 weeks?

Nausea:

Fever:

Drenching night sweats that were so bad you had to change clothes or bed sheets:

Productive cough:

Coughing up blood:

Shortness of breath:

Lumps or swollen glands in the neck or armpits:

Loss of weight without trying:

Diarrhea lasting more than a week:

Brown tinged urine:

Extreme fatigue:

Jaundice or yellow eyes:

Missed periods for last two months:

HIV/AIDS/Hepatitis C Risk

Did you receive a blood transfusion before 1992?

Have you received blood products produced before 1987 for clotting problems?

Was your birth mother infected by Hepatitis C during the time of your birth?

Have you been or are you currently on long-term kidney dialysis?

Have you had unprotected sex with someone who has the blood disease hemophilia?

Have you had unprotected sex with a person who injects drugs?

Have you had unprotected sex with a man who has sex with other men?

Have you had sex in exchange for money or drugs in order to survive?

Have you had unprotected sex with more than one partner in the past 6 months?

Have you had sex or shared needles with a person who has AIDS, HIV+, or Hep C +?

Have you ever injected drugs, even once?

Have you ever been pricked by a needle that may have been infected with HIV or Hep C?

Have you ever had a test for HIV?

If yes, was it within the last six months?

If no, would you like to be tested?

Have you ever had a blood test for Hepatitis C?

If yes, was it within the last six months?

If no, would you like to be tested?

How would you judge your own risk for being infected with HIV? (Please check one)

How would you judge your own risk for being infected with Hepatitis C? (Please check one)

 

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