Questionnaire

"*" indicates required fields

Home Detox Application

Patient Information

Please complete the form so we can assess your suitability for a Home Detox

First Name*

Last Name*

Mobile phone number*

Email*

Date of Birth*

Nominated Carer

The Patient will be required to have a nominated carer, who is staying with them during the detox to supervise the treatment.

Full Name*

Relationship

Email*

Phone*

Medical Questions

Do you have suicidal thoughts?*

Do you have a history of self-harm?*

Have you attempted suicide in the past?*

Do you have any diagnosed mental health conditions?*

Have you ever suffered with liver disease?*

Are you currently under a psychiatrist?*

Have you ever suffered from seizures or fits?*

Have you ever suffered from pancreas disorders?*

Are you allergic to any medication?*

In the last 12 months, have you been unable to remember what happened the night before after drinking?*

Please give any details relating to the question above or the medication taken.

Alcohol-related questions

Are you drinking over 30 units of alcohol per day?*

In the past 12 months, have you failed to perform your usual activity in a day, i.e. go to work?*

Do you struggle to stop drinking once you start?*

In the last 12 months, have you needed an alcoholic drink to get your day started?*

In the last 12 months, have you had a feeling of guilt or remorse after drinking?*

GP Information

GP Name

GP Address

My Address - required for delivery of kit

Street Address*

City*

Postcode*

Country

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