Questionnaire

Please Complete The Form Below For Home Detoxes

Patient Information
Name*
Address*
Telephone Number*
Email*
Do you Skype, FaceTime or WhatsApp?*
Date of Birth*
Date Format: DD slash MM slash YYYY
Skype Username:
Nominated Carer
The patient will be required to have a nominated carer, who is staying with them during the detox to supervise the treatment.
Name*
Permission to contact*
Relationship*
Email Address*
Telephone Number*
Medical Questions
Do you have a history of fits, seizures or epilepsy?*
Please describe*
Do you have a history of self-harm?*
Please describe*
Do you have any suicidal thoughts?*
Please describe*
Have you attempted suicide in the past?*
Please describe*
Do you have any diagnosed mental health conditions?*
Please describe*
Do you have a significant learning disability or cognitive impairment?*
Please describe*
Are you attending any psychiatry services?*
Please describe*
Are you taking any medication?*
Please describe*
Questionnaire
How often do you have a drink containing alcohol?*
How many units of alcohol do you drink on a typical day when you are drinking?*
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
How often during the last year have you found you were not able to stop drinking once you have started?*
How often during the last year have you failed to do what was normally expected from you because of your drinking?*
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?*
How often during the last year have you had a feeling of guilt or remorse after drinking?*
How often during the last year have you been unable to remember what happened the night before, because you had been drinking?*
Have you or somebody else been injured as a result of your drinking?*
Has a relative or friend, doctor or health worker been concerned about your drinking or suggested that you cut down?*
Do you regularly drink between 15 and 30 units of alcohol per day?*
Are you drinking over 30 units per day?*
Pharmacy Telephone Number*
GP Information
Name of GP*
GP Address*
Comments
This field is for validation purposes and should be left unchanged.