Family name and forename
Present address and postcode
Unique identifier
Previously known
Date of birth
Gender
Ethnicity
Referral Source
G.P Name
G.P Address
Other professionals/agencies involved
Next of kin
Dependant children at home
Previously known
Previous Interventions
Presenting problem
Primary drug profile
Secondary drug profile
Injecting
Signs and symptoms of over sedation and/or withdrawal
Consent to assessment
Signed permission to share information with other agencies
Drug Use
Other problem drug profile
Alcohol use
Prescribed drugs/medication
Effects on user (positive and negative)
Problems/concerns
Drug history including alcohol
Living Arrangements
Household composition
Status of residency
Accommodation type
Carer/cared for
Other drug user(s) in household
Housing support needs
Benefits
Heating
Physical Health
Past medical history
Permanent or long-standing health condition or disability
Current care provision
Seen by GP in last 18 months
Current medical condition
Current medication
Current treatments
Registered disabled
Disease Prevention
Sleep patterns
Diet and food preparation
General physical state
Body Mass Index
Injecting practices/techniques
Wound management
Oral health
Vaccination history
History of cervical or breast screening
Mental Health
Past psychiatric history
Current signs and symptoms
Risk assessment
Current medication
Seen by psychiatric services in last 18 months
Current diagnosis
Social Functioning
Relationships
Family contacts
Social contacts
Spiritual and religious matters
Cultural and ethnic matters
Leisure/hobbies
Employment, past and current
Learning
Legal Situation
Current offending behaviour
Previous convictions
Outcomes
Prison
Other
Service User's Perspective
Problems and issues perceived and conveyed by the person
Person's motivation
Advocacy required?
Collateral Information
Carer/significant others' perspective
Other service provider
Biological Measures
Biochemistry
Virology
Hepatitis B
Hepatitis C
HIV
Pregnancy
Readiness to Change
Stage of change
Motivational state
Strengths
Barriers to change
Support system
Self-efficacy
Risk and Safety
Needle sharing/exchange/cleaning
Sharing of injecting paraphernalia including filters, water and spoons
Sexual risk
Blood borne virus
Sexually transmitted diseases
Personal safety- Risk from self
Personal safety- Risk from other
Risk to dependant children
Public Safety