Assessment of misuse
- The actual drugs used: type, quantity on average day, route, minimum for comfort.
- Routine: time, place, people.
- Source of drugs and cost.
- If injecting: site, technique, sharing of needles.
- Why is the patient attending now?
- Drug History: age of first use, injecting history periods of heaviest use or abstinence.
- Treatment history
- Alcohol: see alcohol questionnaires
- Forensic history
- Housing
- Current or past relationships, any children.
- Medical history: hepatitis, pancreatitis, overdoses, DVTs, STDs, septicaemia, HIV testing.
- Mental state: intoxication, coherence, appearance, behaviour, mood, hallucinations, delusions, orientation, concentration, memory, insight
- Physical examination: neglect, scars, stigmata, ataxia, twitching, tremor, neuropathy, eyes, nose mouth, BP, pulse, murmur, liver, colon, wasting, lymphadenopathy
- Patient's view
- Formulation
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