This form is for evaluation / clinical audit purposes only and is a rough indicator of professional impression of recent drug / alcohol related problems in the past month. Specific situations / behaviours are listed only as guiding examples and may not reflect the exact situations / behaviours of the client. (Please ring a number under each heading)

0... e.g., client has a stable place to live and supportive friends or relatives who are drug / alcohol free.

1... e.g., client's living situation may not be stable……., or they may associate with drug users / heavy drinkers……. (Tick one)

2... e.g., living situation not stable, and they either claim to have no friends or their friends are drug users / heavy drinkers.

0... e.g., client has reported no significant health problems.

1... moderate health problems e.g., teeth/sleep problems, occasional stomach pain, collapsed vein, asymptomatic hep B / C / HIV.

2... major problems e.g., extreme weight loss, jaundice, abscesses/infections, coughing up blood, fever, overdoses, blackouts, seizures, significant memory loss, neurological damage, HIV symptoms.

0... e.g., client claims not to inject, or have unsafe sex (except in monogamous relationship with longstanding partner, spouse).

1... e.g., may admit to occasional "unsafe" sexual encounters, or suspected to be injecting but denies sharing injecting equipment.

2... e.g., client may admit to regular "unsafe" sexual encounters, or has recently been injecting and sharing injecting equipment.

0... e.g., client appears well adjusted and relatively satisfied with the way their life is going.

1... e.g., client may have low self-esteem, general anxiety, poor sleep, may be unhappy or dissatisfied with their lot.

2... client has a neurotic disorder e.g., panic attacks, phobias, OCD, bulimia, recently attempted or seriously considered suicide, self-harm, overdose or may be clinically depressed. Or client may have psychotic disorders, paranoia (e.g., everybody is plotting against them), deluded beliefs or hallucinations (e.g. hearing voices).

0... client is in full time occupation e.g., homemaker, parent, employed, or student.

1... e.g., client has some part time parenting, occupation or voluntary work.

2... e.g., client is largely unoccupied with any socially acceptable pastime.

0... e.g., no criminal involvement (apart from possible possession of illicit drugs for personal use).

1... e.g., client suspected of irregular criminal involvement, perhaps petty fraud, petty theft, drunk driving, small scale dealing.

2... e.g., suspected of regular criminal involvement, or breaking and entering, car theft, robbery, violence, assault.

0... e.g., no recent drug / alcohol use.

1... e.g., client suspected of periodic drug / alcohol use, or else may be socially using drugs that are not considered a problem, or may be on prescribed drugs but not supplementing from other sources.

2... e.g., client suspected of bingeing or regular drug / alcohol use.

0... e.g., regular attendance of AA / NA, drug free drop in centre, day centre, counselling, or treatment aftercare.

1... e.g., patchy attendance i.e., less than once a week contact with at least one of the above.

2... e.g., client not known to be using any type of structured support.

0... e.g., attends all appointments and meetings on time, follows suggestions, or complies with treatment requirements.

1... e.g., not very reliable, or may have been reported as having an "attitude" problem or other difficulty with staff.

2... e.g., chaotic, may have left treatment against staff advice or been ejected for non-compliance e.g. drug use, attitude problem.

0... relatively easy going e.g., interviews easily, not time consuming or stressful to work with.

1... moderately challenging e.g., a bit demanding or time consuming, but not excessively so.

2... quite challenging e.g., very demanding, hard work, time consuming, emotionally draining or stressful to see.