Medical Questionnaire Online Form

    Patient Personal Info:

    Forename

    Surname

    Address

    Telephone Number

    Email

    Date of Birth

    Alcohol and Drug History:

    How many days a week do you drink alcohol?

    How many units of alcohol do you drink a day or how much of beer, wine or spirit do you drink a day?

    Do you experience withdrawal symptoms when you stop drinking alcohol?

    What symptoms?

    Do you drink alcohol early morning to stop withdrawal symptoms?

    Have you ever had a seizure after stopping alcohol?

    How many times and when was the last time?

    Have you ever had any liver problems from alcohol abuse?

    Please give details

    When were your last Liver Function blood test and the result?

    Have you ever had medical detox or rehab for alcohol or drugs in the past?

    Please give details – at home, rehab or hospital and any complications encountered

    In the past year, has drinking alcohol affected your job, finances or responsibilities at home?
    YesNo

    In the past year, any feeling of guilt or remorse after drinking alcohol?
    YesNo

    In the past year, have you been unable to remember what happened the night before, because you had been drinking?
    YesNo

    In the past year, have you or somebody else been injured as a result of your drinking?
    YesNo

    In the past year, has a relative or friend or health professional been concerned about your drinking or advised that you cut down?
    YesNo

    Do you abuse any illicit drugs or substance or prescription drugs?

    Please state the drug(s) and how often

    Medical History:

    Please list below any physical health problems you are diagnosed with

    Please list below any mental health problems you are diagnosed with

    Please list below any current medications you are prescribed

    Are you diagnosed withepilepsy

    How many times and last time it happened

    Do you have a history of suicidal thoughts, self-harm, deliberate drug overdose or suicidal attempt?

    Please give details and last time it happened

    Have you ever been sectioned or admitted by the psychiatricteam

    Please give date and details

    Do you have any learning disability or cognitive impairment?

    Give details

    Your GP Information:

    Name of GP

    GP Address

    Consent to contact your GP if necessary?

    Nominated Carer info:

    Note: A nominated carer is a responsible adult (relative, friend or loved) to stay with and support the patient during home detox. No need for previous experience or medical expertise as clear direction will be provided.

    Name

    Permission to contact

    Relationship

    Telephone Number

    Email Address

    Assessment with the Doctor:

    Are you able to use video via Skype, FaceTime or WhatsApp?