Giving up Drinking Help Assessment
Your Details
1) Please advise a first name so I can personalise my response to you.
(This does not have to be your first name)
2) Age
3) Sex M/F
4) Email
5) Religion
(How does this affect your drinking? Does it offer support?)
6) Country of residence
7) Current Work (occupation, full-time/ part time?)
8) Please state and describe any medical conditions
9) People you live with (state relationship/ ages)
(How do they affect your drinking?)
-
10) Physical Disabilities
(Please state and explain if they affect your drinking)
11) Significant history of mental health problems:
(e.g. Periods in psychiatric hospital describe reason, length and frequency. Mental health diagnosis (please state))
12) Medication
(State medication name or type and what you take it for)
13) Are you going through any stress, changes or difficulties at this time?
(Please explain how this is affecting you.)
14) Are there still any aspects of your childhood that still affect you in daily life?
(Please explain how these affect you.)
15) Have you or anyone close to you been affected by any of the following?
(Please explain how this affects you?)
Self harm
Domestic violence
Violence/ aggressive behaviour
Criminal behaviour
Emotional abusive relationship
Prescribed drug misuse
Illegal drug misuse
Others (please specify)
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