Medical Assessment Questionnaire
If you prefer, you may download a .pdf version of this form, print it out and post or fax it to us (details)

Your contact details
Name 
Date of Birth      
Address 
Post Code
Telephone 
Fax (optional)
Mobile (optional) 
E-mail address 
Treatment Requested 
Can you settle your bill for the service in a single payment?  Yes      No

Medical and Psychiatric History

Please select either "Yes " or "No" or "X" for "Don't know". Answer all questions.

  Yes No X
Have you ever suffered from heart or lung problems?
Have you ever suffered from liver failure?
Have you ever suffered from kidney problems?
Have you ever suffered from a head injury?
Have you ever suffered from seizures or fits?
Have you ever suffered from Asthma?
Have you ever suffered from blood pressure problems?
Have you ever suffered from balance problems?
Have you ever suffered from Diabetes?
Have you ever suffered from pancreas disorders?
Have you ever had problems of swelling? (E.g. in the stomach or feet)
Are you allergic to any medication? if yes please tell us what this is.
Have you ever suffered from any mental health problems?
If so, please tell us what the problem was/is.
Have you ever been sectioned under the Mental Health Act?
If so, please tell us when this was and how long you were in hospital.
Have you ever attempted to harm yourself in any way, for example, taken any overdoses, cutting yourself etc.? If so please tell us about this.
Have you ever deliberately attempted to kill yourself?
If the answer to the above question is 'yes' please tell us about this.

Current Situation

Please select either "Yes " or "No" or "X" for "Don't know". Answer all questions.

  Yes No X
Are you suffering from any medical conditions at the moment?
If so, please tell us about this.
Are you currently taking any medication?
If so, please tell us which medicines you are taking - what the dose is and how long you have been taking it/them.
N.B. Please include all medications whether prescribed or bought over the counter.
Have you had a blood test in the last four weeks about which we may contact your doctor? If so, please provide the name, address and phone number of your doctor.
Do you currently use any street drugs, for example, heroin, cocaine, cannabis etc.?
If you are using any non-prescribed drugs you must tell us as this may affect
any prescription we may issue you. Please list all non-prescribed drugs here
Have you ever undertaken a "detox" for alcohol or drug problems in the past?
If so, please tell us when and where it was, how long ago and what you were detoxing from.
Please provide the name, age and address of the adult who has agreed to supervise your medication, should you be issued with a prescription.
Name
Age
Address
What is your relationship to this person?
When did you last see your doctor?
Are you currently being seen by someone from a community drug or alcohol service?
If so, please provide the name, work address and phone number of the staff member
Today's date 18th May, 2012
Is the above information correct at the time of completing this assessment?
Please confirm that you have read our Service Agreement
and that you agree to the terms and conditions it sets out

ReCAPTCHA

This prevents abuse from automated programs usually written to generate spam. They cannot read distorted text. Using this system also helps digitise old books etc. - learn how »

 send »

" As soon as my needs had been professionally assessed by the medic

I was able to start Home Detox right away. "

Find us on Facebook We are on LinkedInk Follow us on Twitter Subscribe to our RSS Feed Check the Addiction Focus Blog Visit our YouTube Channel

Detox at Home - from £995

Home-based alcohol and drug detox services maybe suitable for you.

Affordable, effective & confidential.

Home-based Treatment Services

Our continuing treatment at home promotes recovery while you carry on your normal life at work and at home.

24/7 Addiction Treatment
prices from
£150 per week

How does drinking affect your wallet and your waistline?

BBC Newsbeat's 'booze calculator' has the answer.

Look now »

Start Recovery Now!
You are just a phone call away from addictions recovery.
Call 0845 4567 030
Or complete the form now »

Other Addictions

Addicted to pornography, sex, the internet, shoplifting or anything else?

We can help - call 0845 4567 030

Recovery in the Workplace

We can help your staff towards recovery while they remain at work.

Find out more »

 
Just a phone call away
from addictions recovery
0845 4567 030
Overview
Who we can Help
Start Now!
Services & Prices
Detox at Home
Residential Services
Intervention
Payment Options
Our Agreement
Recovery Journeys
On-line Self Testing
Client Experiences
Continuting Care
Counselling Service
Families & Friends
Intervention
Our Blog
Your Questions
Find us on Facebook
Addiction Focus Blog
See us on YouTube
Services and Support
Employers Guide
Counselling Service
Training for HR
Health Professionals
Partner Agencies
Public Contracts
Addictions UK
England
Ireland
N. Ireland
Scotland
Wales