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MID-OHIO VALLEY FELLOWSHIP HOME
Resident Assessment Form
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Email
*
Your email
Children
*
Your answer
Last Use
*
Your answer
CPS
*
Your answer
Date
*
MM
/
DD
/
YYYY
Time
*
Time
:
AM
PM
Assessment Taken By
Your answer
Callers Name
Your answer
Agency Name (if applicable)
Your answer
Address
*
Your answer
County
*
Your answer
Relationship to Resident
*
Your answer
Phone Number
*
Your answer
Resident Information
Resident Name
*
Your answer
Resident Birthdate
*
Your answer
Resident Age
*
Your answer
Resident Address
*
Your answer
Resident Phone (H)
*
Your answer
Resident Phone (W)
*
Your answer
Current Resident (if other than above)
Your answer
Sex
*
Male
Female
Marital Status
*
Single
Married
Widow
Divorce
Seperated
Employer
Your answer
Employer Address
Your answer
Social Security Number
*
Your answer
Resident Pregnant
*
Yes
No
Other:
If yes, How Many Months?
Your answer
Are you a veteran?
*
Yes
No
Emergency Contact 1 (include name, relationship and phone number)
*
Your answer
Emergency Contact 2 (include name, relationship and phone number)
*
Your answer
Source of Awareness (How did you hear about us?)
*
Website
Social Media
Word of Mouth
Physician
Other:
Required
Substance History
Information Obtained by
*
Resident
Other:
Required
Why do you want treatment now?
*
Your answer
Are you currently using drugs?
*
Yes
No
Are you currently using alcohol?
*
Yes
No
Drug History
Have you used alcohol?
*
Daily
3-5X a week
Weekends
1-8 X a month
Less than 1X a month
Required
Amount
Your answer
Last Use
Your answer
Drinks of Choice
Your answer
Have you used cocaine?
*
Daily
3-5X a week
Weekends
1-8 X a month
Less than 1X a month
Required
Amount
Your answer
Last Use
Your answer
Have you used Heroin?
*
Daily
3-5X a week
Weekends
1-8 X a month
Less than 1X a month
Required
Amount
Your answer
Last Use
Your answer
Route
Your answer
Have you used Marijuana?
*
Daily
3-5X a week
Weekends
1-8 X a month
Less than 1X a month
Required
Have you used Opiates?
*
Daily
3-5X a week
Weekends
1-8 X a month
Less than 1X a month
Required
Amount
Your answer
Amount
Your answer
Last Use
Your answer
Route
Your answer
Have you used Opiates?
*
Daily
3-5X a week
Weekends
1-8 X a month
Less than 1X a month
Required
Amount
Your answer
Last Use
Your answer
Route
Your answer
Have you used Benzos?
*
Daily
3-5X a week
Weekends
1-8 X a month
Less than 1X a month
Required
Amount
Your answer
Last Use
Your answer
Route
Your answer
What is your drug of choice?
Your answer
How old were you when you had your first drink?
Your answer
How old were you when you had your first drug?
Your answer
How long have you been using at this level?
Your answer
Have you tried to quit in the past?
*
Your answer
How many times?
Your answer
Longest time your quit?
Your answer
In the last 6 months, what is the longest period of time you have gone without using drugs or alcohol?
*
Your answer
Previous inpatient treatment for drugs and alcohol?
*
Yes
No
Where, When, Length of time, Abstinent for how long?
Your answer
Where, When, Length of time, Abstinent for how long?
*
Your answer
Where, When, Length of time, Abstinent for how long?
*
Your answer
Where, When, Length of time, Abstinent for how long?
*
Your answer
Have you ever Out-patient treatment for drugs/alcohol problem?
*
Your answer
Where, When, Length of time, Abstinent for how long?
Your answer
Where, When, Length of time, Abstinent for how long?
Your answer
Where, When, Length of time, Abstinent for how long?
Your answer
Where, When, Length of time, Abstinent for how long?
Your answer
Have you attended AA/NA or other support groups?
*
Your answer
Medical History
When you stop drinking or using did you experience any of the following?
*
Tremors
Hallucinations audio/visual/tactile
Seizures
Agitation
Nausea/vomiting
Blackouts
delirium tremors
Insomina
Sweats
irratability
Mood swings
muscle aches
Other:
Required
Have you ever been diagnosed with the following condition?
*
High Blood Pressure
Cirrhosis
Hepatits
liver disease
Diabetes
Tuberculosis
Heart Problems
Coronary Artery Disease
Pancreatitis
Breathing Problems
Difficulty Walking
GI Bleeding
Renal Failure
Inability to take oral meds
Other:
Required
Have you been hospitalized for any of these conditions
*
Yes
No
Required
If so, which ones?
*
Your answer
Do you have any disabilities, limitations or special needs?
*
Yes
No
Required
If yes, explain them.
Your answer
Medical Doctor
Your answer
Phone Number
Your answer
Last Seen
Your answer
A copy of your responses will be emailed to the address you provided.
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