The Kent Center for Human and Organizational Development

401-738-4300 -- 24 Hour Emergency Telephone

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Alcohol/Drug Assessment

Addiction is a disease which, without treatment/recovery, ends in jail, an institution, hospitalization and/or death. The first step is admitting you have a problem. To help you determine this, fill out the following questionnaire.

Congratulations for taking this very important first step on your road to recovery!

How old were you when you first used alcohol? __________
How old were you when you first used drugs? __________
Age of first intoxication? __________
Date(s) last use: __________  Type: __________  Amount: __________
Date(s) last use: __________  Type: __________  Amount: __________
Date(s) last use: __________  Type: __________  Amount: __________

Have you ever had legal troubles (arrested, jail, DUI's)?  Yes ___  No ___
Does using interfere with your eating or sleeping?  Yes ___  No ___
Have you experienced blackouts?  Yes ___  No ___
Does it take more to get the same effect?  Yes ___  No ___
Does it take less to get the same effect? Yes ___  No ___
Do you usually drink/drug with others?  Yes ___  No ___

Longest clean/sober period within the past 6 months: __________
Longest clean/sober period in a lifetime: __________

Have you been diagnosed with any of the following medical problems?
Pancreatitis _____  Heart Trouble _____  Ulcers _____
Esophageal Varices w/ Bleeding _____  Esophageal Varices w/o Bleeding _____
Diabetes _____  Hepatitis _____  STD's _____

Have you ever experienced any of the following withdrawal symptoms?
Seizures _____  DT's _____  Shakes _____  Sweats _____  Irritability _____
Anxiety _____  Nausea _____  Vomiting _____  Insomnia _____
Intense Dreaming _____  Nightmares _____  Delusions (usually paranoid) _____

Answer the following questions, using the last two years as your time frame:

Have you ever felt you should cut down on drinking?  Yes ___  No ___
... or drug use?  Yes ___  No ___

Have you ever been criticized for drinking?  Yes ___  No ___
... or drug use?  Yes ___  No ___

Have you ever felt bad or guilty about drinking?  Yes ___  No ___
... or drug use?  Yes ___  No ___

Have you ever had a drink first thing in the morning (an eye-opener)
to steady nerves or to get rid of a hangover?  Yes ___  No ___

If YES to any of the above, an in-depth substance abuse assessment may be indicated.

To schedule a full assessment, call The Kent Center at 401-732-5656.

 

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The Kent Center Executive Offices 2756 Post Road - Ste 104 Warwick, RI 02886-3003
(401) 691-6000 Emergency (401) 738-4300
Affiliated with Brown University School of Medicine and University of Rhode Island
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