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Client’s Goals
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- Reasons for seeking care
- Immediate and long-term goals related to health-care concerns (i.e., physical and mental health)
- Perceived obstacles to and supports in achieving current goals
- Discussion of the impact of the client’s substance use goals on his/her other health-care goals
- Client’s values and beliefs about the best outcome for himself/herself
- Readiness and stage of change regarding substance use
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Demographic & Socio- Economic Information
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- Age
- Gender: sexual orientation and gender identity and/or gender expression
- Cultural and ethnic background
- Education/employment/income
- Housing
- Relationships
- Legal: past or current involvement with the justice system
- Circle-of-care supports: health-care providers, family, and other social supports
- Cultural and diversity needs
- Spirituality
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Substance Use History
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- Substances used by client
- Age of first use of each substance
- Pattern of use (e.g., amount, frequency, duration of use, etc.)
- Route of substance use (e.g., IV, smoking, snorting, etc.)
- Withdrawal symptoms associated with substance use
- Tolerance to substances
- Substances of concern, as identified by the client
- Access and use of harm reduction strategies (e.g., safer drug use education) and/or supplies (e.g., clean needles)
- Triggers of substance use
- Adverse consequences related to use
- Increasing loss of control over use
- Periods of abstinence and factors that supported abstinence
- Past history of seeking help for substance use
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Physical Health History and Medical Conditions
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- Diagnosed health conditions past and present
- Medication: past and current (include over-the-counter medications and alternative/complementary medications)
- Interventions and procedures
- Experiences with interventions and services
- Chronic pain
- History of seizures
- Dental issues
- Sexually transmitted infections
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Potential infections (resulting from IV drug use and/or high-risk behaviour)
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- Localized and systemic infections or abscesses
- Cellulitis
- HIV
- Hepatitis B
- Hepatitis C
- Infective endocarditis
- Osteomyelitis
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Mental Health History
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- History of mental health problems
- Current mental health concerns
- Current and past interventions for mental health problems (pharmacological and non-pharmacological)
- Experiences with interventions and services for mental health problems
- Trauma (emotional, physical, and psychological)
- History of self-harm
- Suicide attempts or thoughts of suicide
- Feelings of anxiety or depression
- Current ability to cope with emotions
- Resilience and hopefulness
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Family History of Substance Use and Mental Health Concerns
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- Information about relatives who have or have had issues due to substance use or a substance use disorder, and how they have managed (e.g., medications and therapies, current health status, etc.)
- Information about relatives who have or have had mental health concerns, and how they have managed (e.g., medications and therapies, current health status, etc.)
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Resilience and Strengths
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- Client-identified personal strengths and sources of resilience
- Client-identified needs and supports to enhance resilience and strengths
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