Drug addiction questionnaire

The first step toward addiction recovery is a personal email or phone call to our clinic staff. We’ll talk with you about your current circumstances, help evaluate your needs, and make our best recommendations for beginning your (or your loved one’s) recovery. This initial consultation is completely free of charge or obligation. We are available via email, Skype, and phone.
 

First, last name, contact details (address, phone, email):
Date of birth:
What substance do you use now, in what daily doses?
How long are you using drugs (from the moment of first use)?
Did you ever had an overdose, what were the side effects, what kind of help was given?
Please indicate if you suffer from illnesses to any of the folowing organs:
 heart
 lungs
 liver
 digestive system
 other
Did you ever have a head injury which caused loss of consciousness? Was it cured? When and how was it cured?
Are you allergic to anything?
Did you ever have an epileptic attack, loss of consciousness? When and which sort?
Did you ever have problems with depression?
Did you ever have illusions of seeing or hearing things under the influence of narcotics (or without)?
If you were treated before, where and how were you treated and what were the results?
What is your motivation to have a sober life?
What addiction do you seek healing from?