Figure 3-1 Overview of Key Elements for Inclusion in Assessment

Standard Medical History and Physical Exam, With Particular Attention to the Presence of Any of the Following

• Physical signs or complaints (e.g., nicotine stains, dilated or constricted pupils, needle track marks, unsteady gait, tattoos that designate gang affiliation, “nodding off”)
• Neurological signs or symptoms (e.g., blackouts or other periods of memory loss, insomnia or other sleep disturbances, tremors)
• Emotional or communicative difficulties (e.g., slurred, incoherent, or too rapid speech; agitation; difficulty following conversation or sticking to the point)

Skinner Trauma History

Since your 18th birthday, have you

• Had any fractures or dislocations to your bones or joints?
• Been injured in a road traffic accident?
• Injured your head?
• Been injured in an assault or fight (excluding injuries during sports)?
• Been injured after drinking? Source: Skinner et al. 1984.

Alcohol and Drug Use History

• Use of alcohol and drugs (begin with legal drugs first)
• Mode of use with drugs (e.g., smoking, snorting, inhaling, chewing, injecting)
• Quantity used
• Frequency of use
• Pattern of use: date of last drink or drug used, duration of sobriety, longest abstinence from substance of choice (when did it end?)
• Alcohol/drug combinations used
• Legal complications or consequences of drug use (selling, trafficking)
• Craving (as manifested in dreams, thoughts, desires)

Family/Social History

• Marital/cohabiting status
• Legal status (minor, in custody, immigration status)
• Alcohol or drug use by parents, siblings, relatives, children, spouse/partner (probe for type of alcohol or drug use by family members since this is frequently an important problem indicator: “Would you say they had a drinking problem? Can you tell me something about it?”)
• Alienation from family
• Alcohol or drug use by friends
• Domestic violence history, child abuse, battering (many survivors and perpetrators of violence abuse drugs and alcohol)
• Other abuse history (physical, emotional, verbal, sexual)
• Educational level
• Occupation/work history (probe for sources of financial support that may be linked to addiction or drug‐related activities such as participation in commercial sex industry)
• Interruptions in work or school history (ask for explanation)
• Arrest/citation history (e.g., DUI [driving under the influence], legal infractions, incarceration, probation)

Sexual History: Sample Questions and Considerations

• Sexual orientation/preference—“Are your sexual partners of the same sex? Opposite sex? Both?”
• Number of relationships—“How many sex partners have you had within the past 6 months? Year?”
• Types of sexual activity engaged in; problems with interest, performance, or satisfaction—“Do you have any problems feeling sexually excited? Achieving orgasm? Are you worried about your sexual functioning? Your ability to function as a spouse or partner? Do you think drugs or alcohol are affecting your sex life?” (A variety of drugs may be used or abused in efforts to improve sexual performance and increase sexual satisfaction; likewise, prescription and illicit drug use and alcohol use can diminish libido, sexual performance, and achievement of orgasm.)
• Whether the patient practices safe sex (research indicates that substance abuse is linked with unsafe sexual practices and exposure to HIV).
• Women’s reproductive health history/pregnancy outcomes (in addition to obtaining information, this item offers an opportunity to provide some counseling about the effects of alcohol and drugs on fetal and maternal health).

Mental Health History: Sample Questions and Considerations

• Mood disorders—“Have you ever felt depressed or anxious or suffered from panic attacks? How long did these feelings last? Does anyone else in your family experience similar problems?” (If yes, do they receive medication for it?)
• Other mental disorders—“Have you ever been treated by a psychiatrist, psychologist, or other mental health professional? Has anyone in your family been treated? Can you tell me what they were treated for? Were they given medication?”
• Self‐destructive or suicidal thoughts or actions—“Have you ever thought about committing suicide?” (If yes: “Have you ever made an attempt to kill yourself? Have you been thinking about suicide recently? Do you have a plan?” [If yes, “What means would you use?”] Depending on the patient’s response and the clinician’s judgment, a mental health assessment tool such as the Beck Depression Inventory or the Beck Hopelessness Scale may be used to obtain additional information, or the clinician may opt to implement his own predefined procedures for addressing potentially serious mental health issues.)

Source: CSAT 1997a.