Your Personal History

We are hoping to improve assessment and treatment. We are looking at different aspects/factors that include physical conditions, genetics, trauma and other factors that may have affected substance use disorders. Any/all information may be helpful and will be kept confidential.

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* 1. Do you have any history of physical illnesses, injuries, accidents, or procedures?

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* 2. Did you seek medical care or treatment for any of these events?

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* 3. Have you used medications or substances, prescribed or otherwise, to help manage difficulties related to any part of your physical health condition?

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* 4. Do you have any history of mental health issues, diagnoses, or treatment?

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* 5. Did you seek clinical care or treatment for any of these events?

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* 6. Have you used medications or substances, prescribed or otherwise, to help manage difficulties related to any part of your mental health condition?

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* 7. Do you have any known family history of substance abuse and/or addiction?

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* 8. At what age did you begin using substances consistently, whether that was monthly, weekly, or daily?

1 100
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* 9. How much do you associate drinking or using substances with a "high" feeling? (Giddiness, excitement, euphoria, etc.)

1 (Not at all) 10 (I expect this feeling when I take a substance)
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