CareCreds
ENTRY & EXIT SURVEY OF PATIENTS ON CLASS A DRUGS
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Coca Leaves


 
THIS MAY BE FILLED IN ON-LINE OR BY PHONE INTERVIEW 

CLINICAL CARER'S EMAIL ADDRESS:
 * required
Patient's First Name:
 * required
Patient's Last name:
 * required
 PATIENT  INFORMATION BOTH AT ENTRY AND FOLLOW-UP:
Patient's Sex:
Patient's Date of Birth (e.g. 01/02/1994):
 * required

Patient's current Mobile Phone Number (or any number he/she can be contacted on)

 * required
Are you happy to join or continue the CareCred scheme and agree to your data being analysed and published anonymously and  are you happy to be texted at random to go for urine tests to ensure you are street clean etc?
What Class A drugs are you using now?
Current Severity and frequency of Class A drugs use now?
What is the worst Severity and frequency of Class A drugs use you have ever had?

How much money on average is your habit costing you each week?

How much of your time on average do you spend on your habit ?

Has your habit ever damaged your social life e.g. lost you a job, friends or involved you in crime? 

Has your habit ever damaged your family life e.g. lost you relationships? 

Has your habit ever damaged your physical health? 

Has your habit ever damaged your mental health? 

How damaging is your habit now?

Are you receiving regular opiate substitutes (Methadone, Subutex or Codeine etc) from a proper medical source  ?

Have you ever had a Detox or Rehab?

How bad is your mental health now?

Have you had medical treatment for Panic or Anxiety?

Have you had medical treatment for psychosis e.g. paranoia ?

Have you had medical treatment for Depression?

During the past month how generally happy and relaxed have you felt?

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How happy have you been with the help you have had from Voluntary services?

How happy have you been with the help you have had from Social services?

How happy have you been with the help you have had from Housing services?

How happy have you been with the help you have had from Hospital services?

How happy have you been with the help you have had from GP services?

How happy have you been with the help you have had from Drug and Alcohol Team?

How happy have you been with the help you have had from Police?

How happy have you been with the help you have had from the Prison and Probation services?

Did you have severe or prolonged stress before you started your substance abuse?
During the last 2 weeks have you had flashback memories of this stress?

During the last two weeks have you had frequent personality changes so you become less mature and this upsets other people?

Do you have difficulty reading and or writing?
Do you still keep in contact with your birth or adopted family?
Do you have children of your own?
What sort of relationship do you have with friends and others?
Have you ever worked and do you have a job now?

What the age (in years) were you when you first started your Class A addiction?

Do you inject and/or have unprotected sex?
Have you had HIV or Hepatitis?
Have you had to have medical treatment last year because of health damage due to substance abuse?
Do you feel you are addicted to Speed or other illegal uppers?
Are you a current Cigarette smoker?
Do you think you are addicted to alcohol? i.e. frequently cannot control the craving to have six or more drinks on one occasion 
(1 drink = Half Pint of beer or 1 glass of wine or one single spirits)               
In the last two weeks do you feel you have been addicted to prescribed or street Benzodiazepines or Sleeping tablets?
In the last 2 weeks do you feel you have been addicted to Pot?

How often have you had bad cravings to use something to get high or relieve stress or boredom in the last two weeks?

How often have you felt you want to give up all drugs in the past two weeks?
How often have you felt badly stressed by anything in the past two weeks? (e.g. Debts, Housing, personal conflicts etc)

What are the main stresses in your life now?

Have you committed any crime ?
How often have you been a nuisance to others in the past two weeks?
During the last 2 weeks how often have you taken sweaty exercise?

During the last 2 weeks how often have done any non-physical activity or hobbies that you enjoyed?

Do you have firm plans for the future?

Do you have problems sleeping?
During  the past month have you OFTEN been bothered by little interest or pleasure in doing things?

During the past month have you often been bothered by feeling down, depressed or hopeless?

During the last 2 weeks how often have you felt self-destructive?

During the last 2 weeks how often have you felt aggressive or violent?

During the past month how generally happy and relaxed have you felt?

How much are you using  alternatives to taking drugs in order to enjoy your life?

 
 
 
 
 
 
 

USE THE BOX BELOW TO SEND US ADDITIONS,COMMENTS

OR  CORRECTIONS TO ANY DATA SUBMITTED

   
 
CLINICAL CARER's EMAIL ADDRESS:
 * required
Patient's First Name:
 * required
Patient's Last name:
 * required
Patient's Sex:

Patient's current Mobile Phone Number (or any number he/she can be contacted on)

 * required
Comments:
 

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