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ALCOHOL
ABUSE
Definition: Alcohol abuse, dependence or addiction Chronic heavy
drinking, intoxication or binge drinking. Alcohol use resulting in
impairment of health.
A. Date of
last drink? Reason for stopping?
Number of relapses if
any? Dates?
B. Is
Client currently a member of AA, NA, CA,
or any other
support group?
C. Did the
client go through a formal treatment program?
Was treatment on an
Inpatient or Outpatient basis?
Date(s)?
D. Any
traffic violations or legal problems due to
alcohol use? Details
and Date(s)?
E. Has
Blood Profile (Including liver function tests)
been done within last
12 months? Results?
F. Any
residual damage? (ie: liver damage or memory
loss) If yes, type of
damage and date diagnosed.
G. Is
client taking Antibuse? Details?
H. Was
client ever treated for drug problems? If yes,
answer questions to #6
Drug Abuse,
I. Current
family status (ie: married, divorced, single,
children, etc.)
J. Answer
ALL questions listed under
#1
General Risk Profile
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CANCER
Definition:
A cellular tumor (new growth). Exhibits properties of invasion and
metastasis (transfer of the disease to a part of the body not directly
related). Cancers can be carcinoma (originates in the epithelial tissue,
covering the body, lining cavities and ducts) or sarcoma (originating in
mesodermal tissue, which is connective tissue, bone, cartilage) in
addition to many other types of cancer.
A. Type
of Cancer? Location of
Cancer?
B.
If the Pathology Report is available, please FAX
to us for a firm quote.
If not, then give us tumor
details:
Stage? Grade?
Size?
IMPORTANT NOTE: If cancer history is within 10
years then the pathology report must be provided.
C.
Has the client had any reoccurrence?
D.
Was there any metastasis (spread) to any other
organ or tissue?
If so, where?
E.
Describe treatment
1) Surgery: Date(s) started? Date(s)
ended?
2) Chemotherapy: Date(s) started?
Date(s) ended?
3) Radiation: Date(s) started?
Date(s) ended?
F.
Any other treatment(s) or medication(s)?
If yes,...Type(s)? Date(s) started? Date(s) ended?
G.
Answer ALL questions listed under
#1 General Risk Profile |