Substance Abuse

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Personal Information:

Gender

History of Substance use

First contact with alcohol/drug
Course of use of Primary Drug(s)

Drug- related problems

Non- dependent use of other drug(s)

Other psychiatric History

Personal History

Birth History

Early Development History

Childhood History

Neurotic traits

Scholastic and extracurricular activities

Scholastic performance
Disciplinary action
Attendance
Peer group judgement
Relation with authorities

Legal History:

Home environment:

(Patient’s relationship with family members, Interpersonal relationship among family members, Decision Making process, Interaction pattern and Family support system)
(include knowledge regarding illness and misconceptions, if any)

Scholastic history:

Type of school
Scholastic performance

Play History:

Play behaviour
Play preference
Knowledge of games governed by rules
Behaviour while playing in group

Sexual and marital history:

Attained menarche
(Duration of usual cycle, regular/irregular, associated with physical or psychological symptoms or not, information and attitude towards mensuration, last menstrual period, duration and reasons of amenorrhea, if any)
(current and past, include any details of childhood sexual abuse if available)
(if married, then mention age at marriage, parental consent, child’s consent and relevant details about spouse, role allocation and sharing of responsibilities between partners, sexual relations and contraception, genogram for family of procreation)

Pre morbid Personality:

Impression:

Mental Status Examination

Cognitive Functions

Affect

Perception and other phenomenon:

Judgment
Insight

Contact Information

My current residential address:

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