INTAKE ASSESSMENT

CLIENT NAME:
DATE OF BIRTH:
ADMIT DATE/ TIME
INSURANCE NAME
DRUG OF CHOICE
Alcohol Opiates Methamphetamine Benzodiazepine Cannabis Cocaine Other
DRUG OF CHOICE ALCOHOL
Alcohol
LAST USED(date/time)
AMOUNT USED (Quantity)
FREQUENCY (how often)
Duration(how long)
DRUG OF CHOICE OPIATES
Opiates
LAST USED(date/time)
AMOUNT USED (Quantity)
FREQUENCY (how often)
Duration (how long)
DRUG OF CHOICE METHAMPHETAMINE
Methamphetamine
LAST USED(date/time)
AMOUNT USED (Quantity)
FREQUENCY (how often)
Duration (how long)
DRUG OF CHOICE BENZODIAZEPINE
Benzodiazepine
LAST USED(date/time)
AMOUNT USED (Quantity)
FREQUENCY (how often)
Duration (how long)
DRUG OF CHOICE CANNABIS
Cannabis
LAST USED(date/time)
AMOUNT USED (Quantity)
FREQUENCY (how often)
Duration (how long)
DRUG OF CHOICE COCAINE
Cocaine
LAST USED(date/time)
AMOUNT USED (Quantity)
FREQUENCY (how often)
Duration (how long)
DRUG OF CHOICE OTHERS
Others
LAST USED(date/time)
AMOUNT USED (Quantity)
FREQUENCY (how often)
Duration (how long)
VITAL:
BP
P
RR
Temp
BAL
CIWA Score:
COWS Score
Hx of Seizure
Yes No last episode?
Hx of head injuries
Yes No when?
Hx of DT
Yes No when?
Suicidal or Homicidal Thoughts?
Yes No
Hx of 5150 : Yes No when?
ROS:
N/V
Diarrhea
Constipation
Fever
SOB
Body Ache
HA
Chest pain
Anxiety
Running nose
Patient denies any nausea, vomiting, diarrhea, chest pain, shortness of breath, abdominal pain, headache, fever. chills, body ache
How many times in rehab?
When was the last rehab?
How long did you stay sober?
When did you relapse?
Medical Problems:
HTN
Diabetes
Dyslipidemia
Stroke
Asthma
COPD
h/o Tuberculosis
Others
History of Surgery:
Gastric bypass
Appendectomy
Hysterectomy
Others
C-section
Heart surgery
Pacemaker
History of Mental Health:
Anxiety
Depression
Bipolar
Schizophrenia
PTSD
ADHD
Others
Insomnia? Yes No
do you take any sleep aid : Yes No Hours Sleep?
SMOKER? Yes No
how long have you been smoking?
HIstory of Asthma : Yes No
Hx of COPD : Yes No
Hx of Tuberculosis : Yes No
Allergies : NKDA Others
Medications Lists :
Living situation: ALONE WITH FRIENDS WITH FAMILY HOMELESS OTHER
Does anyone drink or use drugs at home? Yes No . If yes, Who?
Family History of Alcohol and drug abuse? Yes No If yes, Who?
Marital Status: SINGLE MARRIED SEPARATED DIVORCED DOMESTIC PARTNER OTHER
Highest Level of Education: High School College Trade School Other
Employed? Yes No
How long at this job?
if NO, Last time you are employed?
Current /Past legal Issues : Yes No
DUI : Yes No
Disability Yes No If yes, Why?
Staff Name
Staff Signature

CORONAVIRUS DISEASE (COVID-19) SCREENING QUESTIONNAIRE

CLIENT NAME
CLIENT ADMISSION DATE:
Have you traveled to Asia or Europe since the winter of 2019? Yes No
If yes, what countries or parts of countries have you visited?
Have you or any family members been exposed to coronavirus? Yes No
Are you at risk for exposure to coronavirus? Yes No
Are you experiencing shortness of breath, coughing, fever, or other symptoms of coronavirus and/or flu or flu-like symptoms? Yes No
If yes, have you been tested for the coronavirus or are you willing to be tested? Yes No
Approved for Admission Yes No
Staff Printed Name
Date
Staff Signature

Bella Nirvana Center

Drug Test Screening
Client Name:
Date:
DOB:
BP:
P:
BAL:
DRUG POSITIVE NEGATIVE
THC
COC
OPI
AMP
MET
PCP
BZD
BAR
MDMA
MTD
OXY
BUP
PREGNANCY TEST : N/A POSITIVE (+) NEGATIVE (-)
COVID TEST ( RAPID TEST) : N/A POSITIVE (+) NEGATIVE (-)
Provider Signature:
Date