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FOR STAFF ONLY
Please complete the following form
as best as you can to help us
understand you and your needs.
Tick the boxes that best describe your situation,
and write in the spaces provided.
Don’t worry if you cannot complete
all the questions.
Your worker will go over everything
with you. And if you prefer not to
complete it at all, that’s OK too.

Clinician name:

Agency: none Catchment: none

Date: Signature:
Version No. 2
 UR Number:
The following questions ask about how you are going with your alcohol
or drug use and other areas of your life. This will help us see how you progress.
STAGE: Start of treatment Review

SECTION 1: SUBSTANCE USE

In the past four weeks (28 days) have you used any of the following substances? (If you were in hospital/
prison/rehab in the previous month, consider your substance use in the four weeks before that) Yes No (if no skip to section 2)
If yes, record number of days and how much you used in the past four weeks. If yes, days of use (1-28)

Alcohol No Yes: ...................................................

Cannabis (e.g. marijuana, pot, grass, hash, synthetic cannabis etc) No Yes: ..................................................

Methamphetamine (e.g., ice, speed, base) No Yes: ..................................................

Other amphetamine type stimulants (e.g. MDMA /ecstasy, diet pills etc) No Yes: ..................................................

Prescribed sedatives or sleeping pills (e.g. benzodiazepines, xanax, valium, serapax, rohypnol, stilnox etc) No Yes: ..................................................

Non-prescribed benzodiazepines No Yes: ..................................................

Prescribed Opioids (e.g. methadone/buprenorphine) No Yes: ..................................................

Non-prescribed Opioids (e.g. heroin, codeine, methadone, oxycodone, morphine, fentanyl etc) No Yes: ..................................................

Cocaine No Yes: ..................................................

Inhalants (e.g. nitrous, glue, petrol, paint thinner, Amyl etc) No Yes: ..................................................

Hallucinogens (e.g. LSD, acid, mushrooms, PCP, ketamine, synthetic hallucinogens etc) No Yes: ..................................................

Tobacco No Yes: ..................................................

GHB No Yes: ..................................................

Other substances (e.g. steroids caffeine/energy drinks, new and emerging drugs etc) No Yes: ..................................................

Have you injected drugs in the past four weeks? (If no, skip to section 2) No Yes Number of days injected: ...................................................................

If yes, did you inject with equipment used by someone else? No Yes

SECTION 2: HEALTH AND WELLBEING

What is your employment status? Employed Unemployed Studying Home duties Other (Please specify):...................................................

How many days of paid work (not including voluntary work) have you had in the past four weeks? .......................................................................................................................
How many days of school, tertiary education or vocational training have you had in the past four weeks? ..........................................................................................................
In the past four weeks:
What type of accommodation have you been living in in the past 4 weeks?
(e.g. private residence, boarding house, residential care facility):

Have you been homeless? No Yes.

Have you been at risk of eviction? No Yes.
Have you been arrested? No Yes.
Have you been violent (incl. family violence) towards someone? No Yes.
Has anyone been violent (incl. family violence) towards you? No Yes.
Have you been attended to by an ambulance or been in hospital? No Yes.
How would you rate your psychological health status in the past four weeks (anxiety, depression and problem emotions and feelings)
POOR 0 1 2 3 4 5 6 7 8 9 10 GOOD
How would you rate your physical health status in the past four weeks (extent of physical symptoms and bothered by illness)
POOR 0 1 2 3 4 5 6 7 8 9 10 GOOD
How would you rate your overall quality of life in the past four weeks (e.g. able to enjoy life, get on well with family and partner, satisfied with living conditions)
POOR 0 1 2 3 4 5 6 7 8 9 10 GOOD

FOR STAFF ONLY

Clinician name: Position: Signature: Date:

1
 UR Number:

ALCOHOL USE (AUDIT)

The following questions will give us a picture of your recent alcohol use, and will help us determine how best to
help you. Please circle the response that best describes your drinking. If you haven’t been drinking alcohol you
don’t need to answer the questions.
Have you drunk any alcohol in the last year? (Please tick yes or no)
Yes Please answer the questions below No If you answer no, skip to the next page

0 1 2 3 4

How often do you have a drink Monthly 2-4 times 2-3 times 4 or more
1 Never
containing alcohol? or less a month a week times a week

How many drinks containing alcohol do you

2 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
have on a typical day when you are drinking?

How often do you have six or more Less than Daily or

3 Never Monthly Weekly
drinks on one occasion? monthly almost daily

How often during the last year have

Less than Daily or
4 you found that you were not able to Never Monthly Weekly
monthly almost daily
stop drinking once you had started?

How often during the last year have

Less than Daily or
5 you failed to do what was expected Never Monthly Weekly
monthly almost daily
of you because of drinking?

How often during the last year have you

Less than Daily or
6 needed a first drink in the morning to get Never Monthly Weekly
monthly almost daily
yourself going after a heavy drinking session?

How often during the last year have you had Less than Daily or
7 Never Monthly Weekly
a feeling of guilt or remorse after drinking? monthly almost daily

How often during the last year have you

Less than Daily or
8 been unable to remember what happened Never Monthly Weekly
monthly almost daily
the night before because of your drinking?

Have you or someone else been

9 No Yes, but not in Yes, during
injured because of your drinking? the last year the last year

Has a relative, friend, doctor, or other

10 health care worker been concerned about No Yes, but not in Yes, during
your drinking or suggested you cut down? the last year the last year

FOR STAFF ONLY

Clinician name: Position: Signature: Date:

2
 UR Number:

USE OF DRUGS OTHER THAN ALCOHOL (DUDIT)

The next questions will help us to understand whether use of all drugs other than alcohol is a problem for you.
This includes illicit drugs & pharmaceutical medications (e.g. sleeping pills, pain killers). It does not include
medication that you take as prescribed by your doctor. Please circle the response that best describes your use
of all drugs (other than alcohol). If you haven’t been using any, then you don’t need to answer the questions.
Have you used drugs other than alcohol in the last year?
Yes Please answer the questions below No If you answer no, skip to the next page

0 1 2 3 4

Monthly 2-4 times 2-3 times 4 or more

1 How often do you use drugs other than alcohol? Never
or less a month a week times a week

How often do you use more than one Monthly 2-4 times 2-3 times 4 or more
2 Never
drug on the same occasion? or less a month a week times a week

How many times do you take drugs on

3 0 1 or 2 3 or 4 5 or 6 7 or more
a typical day when you use drugs?

Less than Daily or

4 How often are you influenced heavily by drugs? Never Monthly Weekly
monthly almost daily

Over the past year, have you felt your longing for Less than Daily or
5 Never Monthly Weekly
drugs was so strong that you could not resist it? monthly almost daily

Has it happened, over the past year,

Less than Daily or
6 that you have not been able to stop Never Monthly Weekly
monthly almost daily
taking drugs once you started?

How often over the past year have you

Less than Daily or
7 taken drugs and then neglected to do Never Monthly Weekly
monthly almost daily
something you should have done?

How often over the past year have you

Less than Daily or
8 needed to take a drug the morning after Never Monthly Weekly
monthly almost daily
heavy drug use the day before?

How often over the past year have you

Less than Daily or
9 had guilt feelings or a bad conscience Never Monthly Weekly
monthly almost daily
because you used drugs?

Have you or anyone else been hurt (mentally

10 No Yes, but not in Yes, during
or physically) because you used drugs?
the last year the last year

Has a relative or a friend, a doctor or a nurse, or

11 anyone else been worried about your drug use or No Yes, but not in Yes, during
said to you that you should stop using drugs? the last year the last year

FOR STAFF ONLY

Clinician name: Position: Signature: Date:

3
 UR Number:

HOW HAVE YOU BEEN FEELING

DURING THE PAST 30 DAYS? (K10)
The following questions ask about how you have been feeling during the past 30 days. It’s important to
understand how you are feeling and where you are at. For each question, tick the box that best describes
how often you had this feeling.
DURING THE PAST 30 DAYS, NONE OF A LITTLE OF SOME OF MOST OF ALL OF THE
HOW OFTEN DID YOU FEEL THE TIME THE TIME THE TIME THE TIME TIME
1 2 3 4 5

1 ...tired for no good reason?

2 ...nervous?

...so nervous that nothing

3
could calm you down?

4 ...hopeless?

5 ...restless or fidgety?

...so restless that you

6
could not sit still?

7 ...depressed?

...so depressed that nothing

8
could cheer you up?

9 ...that everything was an effort?

10 ...worthless?

Thank you for completing this form. Please hand it to the worker who will review your responses and will be able to address any questions you have.

FOR STAFF ONLY

Clinician name: Position: Signature: Date:

4