Registered Nurses' Association of Ontario

Key Areas for Comprehensive Assessment

  • The list below lists key areas for comprehensive assessment that nurses and other health-care providers should include when conducting an assessment with clients at risk for or experiencing a substance use disorder.  
  • If a health-care provider is unfamiliar with the key areas for comprehensive assessment listed in the link below, the expert panel recommends that the provider seek out appropriate support from an expert.

Client’s Goals

  • 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

Demographic & Socio- Economic Information


  • 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

Substance Use History


  • 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

Physical Health History and Medical Conditions


  • 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

Potential infections (resulting from IV drug use and/or high-risk behaviour)


  • Localized and systemic infections or abscesses
  • Cellulitis
  • HIV
  • Hepatitis B
  • Hepatitis C
  • Infective endocarditis
  • Osteomyelitis

Mental Health History


  • 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

Family History of Substance Use and Mental Health Concerns


  • 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.)

Resilience and Strengths


  • Client-identified personal strengths and sources of resilience
  • Client-identified needs and supports to enhance resilience and strengths


Addiction and Mental Health
Engaging Clients who Use Substances
Point of Care Resources