Family Questionnaire

Patient Name: _________________________________________________________________

Name: ________________________________________________ Date:__________________

Address: _____________________________________________________________________

Home Phone: ________________________ Work Phone: ___________________________

Relation to Patient: _____________________________________________________________

Please list the people who live with the Patient and include their ages if you know them and their relationship to the Patient.

_____________________________________ ______ _______________________________
_____________________________________ ______ _______________________________
_____________________________________ ______ _______________________________
_____________________________________ ______ _______________________________

Please indicate the most appropriate answer or answers in your opinion. If no answer given is appropriate, fill in your own answer. The information you share will be used to develop the best possible treatment plan for your loved one.

TYPE OF MOOD-ALTERING CHEMICALS USED BY PATIENT:

_____Alcohol _____Hallucinogens
_____Cocaine _____Stimulants
_____Tranquilizers _____Pain Pills
_____Narcotics _____Marijuana
_____Sleeping Pills _____Other (Please list_ _________________________

PATTERN OF DEPENDENCY (How frequently the Patient drinks or uses.):

_____Daily
_____Periodic (a fairly regular pattern such as week-ends.)
_____All day
_____Occasionally (on and off with no particular pattern.)
_____Drinking/using drugs less but having more problems.

PATIENT’S AWARENESS OF PROBLEM:

_____No awareness (i.e.: “not worse than anyone else”)
_____Minimal awareness (i.e.: “I can take it or leave it alone; I’m not hurting anyone but myself.”)
_____Admits to problem (i.e.: “I can’t help it, something’s bothering me.”)
_____Well aware of the problem and accepts responsibility for change.

DURATION OF THE PROBLEM:

_____1-3 years
_____5-6 years
_____7-10 years
_____11-15 years
_____16 or more years

LONGEST PERIOD OF NOT DRINKING OR USING DRUGS SINCE BEGINNING:

_____Only a matter of days at a time
_____Only a matter of weeks at a time
_____Up to a month at a time
_____From 1 to 3 months at a time
_____From 6 to 12 months at a time

ARE THERE ANY OTHER PROBLEMS IN CONNECTION WITH OR RELATED TO THE ALCOHOL OR DRUG PROBLEM?

_____Not to my knowledge
_____Job problems
_____Affairs outside marriage
_____Legal problems
_____Financial problems
_____Martial problems
_____Suicide attempts
_____Spiritual problems
_____Getting away from hobbies & former leisure activities

PREVIOUS ATTEMPTS AT TREATMENT:

_____Dry out periods in hospitals (Detox)
_____Alcohol or drug treatment program
_____Hospital psychiatric treatment
_____Alcoholics Anonymous/Narcotics Anonymous
_____Medical treatment by private physician
_____Self
_____Out Patient treatment with (check those that apply)

_____Psychiatrist _____Counselor
_____Psychologist _____Mental Health Center

COMMENTS ON PREVIOUS TREATMENT INCLUDING TYPE AND NUMBER OF ATTEMPTS WITH APPROXIMATE DATES:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
HOW DOES THE PATIENT FEEL TOWARD ALCOHOLICS/NARCOTICS ANONYMOUS?

_____Critical of AA/NA Program
_____Critical of AA/NA Members
_____”Good program, but not for me.”
_____AA/NA is the answer to the problem
_____Has no knowledge of the organizations

PREVIOUS ATTEMPTS IN ALCOHOLICS ANONYMOUS/NARCOTICS ANONYMOUS

_____Attend a few meetings to try it
_____Regular participation for a brief period
_____Past participation but no longer going
_____No participation
_____Attended only to pacify others

HOW DO YOU FEEL TOWARD AL-ANON/NAR-ANON (The program for the Alcoholic’s/Drug Addict’s family)?

_____No knowledge of Al-Anon/Nar-Anon
_____No past experience
_____Some past experience
_____I am presently associated with Al-Anon or Nar-Anon
_____I intend to go to an Al-Anon or Nar-Anon group
_____I don’t intend to go to an Al-Anon or Nar-Anon group

HOW DO YOU FEEL TOWARD THE PATIENT? (Check all that apply)

_____The Patient could stop drinking/using if he/she desired
_____If the Patient really loved me, he/she would do this
_____The Patient is a sick person and needs treatment
_____Regarding the Patient, I am feeling:

_____Angry/resentful _____Guilty
_____Scared _____Hurt _____Confused

WHY DO YOU THINK THE PATIENT HAS SOUGHT TREATMENT AT THIS TIME? (Check all that apply)

_____Felt that problem was serious and treatment necessary
_____To comply with someone else’s wishes (explain)__________________________________
_____________________________________________________________________________
_____To avoid a legal problem
_____To avoid a divorce or separation
_____To keep from losing job
_____Frightened by health problem

WOULD YOU COME FOR CONSULTATION WITH A STAFF MEMBER IF YOU WERE ASKED?

_____Yes _____No

IS THERE ANY OTHER INFORMATION THAT YOU FEEL WE SHOULD KNOW?

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

The following is a list of symptoms that occur frequently in the lives of some of our Patients. Please answer the following yes or no and explain when you think it will be helpful.

1. Blackouts (a memory lapse without loss of consciousness)?
2. Hiding or protecting supply of alcohol or drugs?
3. Can the Patient stop once he/she starts using alcohol/drugs?
4. Making excuses for using alcohol/drugs?
5. Violent and/or abusive behavior?
6. Inability to predict the Patient’s behavior after he/she begins?
7. Have you noticed a change in pattern of Patient’s usage? (Example: Week-end to daily usage.)
8. Unreasonable resentments? (Resents past or present behavior or attitudes of family or friends holds grudges.)
9. Has the drinking/drug using resulted in a change of family activities?
10. Change in sexual drive or sexual problems?
11. Binges or benders? (Patient drinks or uses drugs for days or weeks at a time?)
12. Tremors or other physical problems related to alcohol or drug usage? (Shaking or trembling of hands, nausea/vomiting stomach pain, flushed color, sweating, etc.)
13. Narrowing range or lack of interests and activities?
14. Changing type of friends or changing attitudes toward friends.
15. Have you ever threatened to leave if Patient did not do something about the usage of alcohol and/or drugs?
16. Has physician ever told Patient that his/her use of alcohol or other drugs was injuring his/her health?
17. Has the Patient ever failed to do some of the things he/she should do, such as keeping appointments, getting things done around the home or going to his/her job because of the alcohol or drug usage?
18. Has the Patient ever been threatened with suspension/being fired from a job due to this problem?
19. Have you or other family members ever complained that the Patient spends too much money for alcohol or drugs?

FAMILY DATA

Date: ____________________________ Time: __________________________

Name: __________________________________ Relation to Patient: _______________

Address: _______________________________________________ Zip: ______________

Phone: (_____)_______-_____________ Birth date: _______________ Age: ___________

First met Patient: When: ______________________________________________________

Where: ____________________________________________________________________

Your drinking/drug use history: First drink/use at age: _______________________________

What I experienced: _________________________________________________________

Is drinking/using daily or sporadic? ______________________________________________

What drank/used? ___________________________________________________________

How long? ______________________________ How much?_________________________

Past treatment experience: None_________ With Patient__________ For self____________

When? ______________________ Where?_______________________________________

Why?_____________________________________________________________________