PRE-AMBLE
Please complete this assessment questionnaire as completely as you are able. A nurse will go through the results with you at your chosen appointment time. 

CONSENT
Please provide your consent for your data to be used confidentially to provide services to you, and anonymously to support clinical research. 
	I consent	
	
YOUR INFORMATION
This is data we collect about you to ensure we are able to contact you, as well as demographic data we are required to collect
Full Name:  	
Marital status:	 Single      Married/Defacto      Divorce/Separated      Widowed	
Primary Contact Number: 	Alternative Contact Number (if available): 	
E-mail address: 	
Street Address: 	State: 	Postcode: 	
Accommodation type:       Owned        Rented        Public        Hostel        Other 	
DOB: 	Gender: 	
Sexual Orientation: (Straight; Gay or Lesbian; Bisexual; I use a different term – please specify; Don’t know; Prefer not to answer)	
Ethnicity: (Oceanian; North-West European; Southern / Eastern European; North African / Middle Eastern; South-East Asian; North-East Asian; Southern and Central Asian; Peoples of the Americas; Sub-Saharan African; Other/Unsure)	
Are you Aboriginal or Torres Straight Islander: (No, Yes – Aboriginal, Yes – Torres Straight Islander, Yes – Both, Prefer not to say)	
What is your first language: 	Interpreter needed:     Y          N 	

GP INFORMATION                	
GP name:  	
Street address: 	Phone no.: 	
Suburb: 	State: 	Postcode: 	
Date of referral:
     /    /	Date of Assessment:
    /    /	Referral Source:	

NEXT OF KIN / SUPPORT PERSON 
Please provide details of your preferred contact person (this may be next of kin, or a friend)         	
Name: 	
Best contact number: 	E-mail address: 	
Aware considering detox:        Y      N	Consent to share information:     Y    N	
Do you have children?	 Yes    No	Are you pregnant?	 Yes    No	Number of children	
	
If so where do they live?	 Living with you       Living with other family member      In care	

Alcohol Use Profile	
Do you suffer with: (tick all that apply)	
	Impaired control of your drinking	
	Craving / compulsion to drink	
	Drinking ‘taking over your life’	
	Tolerance to alcohol	
	Withdrawal symptoms when you don’t drink	
	Persistent use despite knowing it is harming you	
How often do you have a drink containing alcohol?	Never	Monthly or Less	2-4 times per month	2-3 times per week	4+ times per week	
How many units of alcohol do you drink on a typical day when you are drinking?	1 - 2	3 - 4	5 - 6	7 - 9	10+	
How often have you had 6 or more units if female or 8 or more if male, on a single occasion in the last year?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily	
How often during the last year have you found that you were not able to stop drinking once you had started?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily	
How often during the last year have you failed to do what was normally expected from you because of your drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily	
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily	
How often during the last year have you had a feeling of guilt or remorse after drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily	
How often during the last year have you been unable to remember what happened the night before because you had been drinking?	

Never	

Less than monthly	

Monthly	

Weekly	

Daily or almost daily	
Have you or somebody else been injured as a result of your drinking?	No		Yes, but not in the last year		Yes, during the last year	
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?	No		Yes, but not in the last year		Yes, during the last year	

Have you been through an alcohol detox before?	Yes	No	
If yes, please provide details, including any detox medications you were taking:

Please recall a typical period of heavy drinking in the last 6 months.

When was this? Month:                                 Year:                                 

Please answer all the following questions about your drinking by circling your most appropriate response.

During that period of heavy drinking:

1.	The day after drinking alcohol, I woke up feeling sweaty.

	 Almost never    Sometimes    Often    Nearly always

2.	The day after drinking alcohol, my hands shook first thing in the morning.

	 Almost never    Sometimes    Often    Nearly always

3.	The day after drinking alcohol, my whole body shook violently first thing in the morning if I didn't have a drink.

	 Almost never    Sometimes    Often    Nearly always

4.	The day after drinking alcohol, I woke up absolutely drenched in sweat.

	 Almost never    Sometimes    Often    Nearly always

5.	The day after drinking alcohol, I dreaded waking up in the morning.

	 Almost never    Sometimes    Often    Nearly always

6.	The day after drinking alcohol, I was frightened of meeting people first thing in the morning.

	 Almost never    Sometimes    Often    Nearly always

7.	The day after drinking alcohol, I felt at the edge of despair when I awoke.

	 Almost never    Sometimes    Often    Nearly always

8.	The day after drinking alcohol, I felt very frightened when I awoke.

	 Almost never    Sometimes    Often    Nearly always

9.	The day after drinking alcohol, I liked to have an alcoholic drink in the morning.

	 Almost never    Sometimes    Often    Nearly always

10.	The day after drinking alcohol, I always gulped my first few alcoholic drinks down as quickly as possible.

	 Almost never    Sometimes    Often    Nearly always

11.	The day after drinking alcohol, I drank more alcohol to get rid of the shakes.

	 Almost never    Sometimes    Often    Nearly always

12.	The day after drinking alcohol, I had a very strong craving for a drink when I awoke.

	 Almost never    Sometimes    Often    Nearly always

13.	I drank more than a quarter of a bottle of spirits in a day (OR 1 bottle of wine OR 7 beers).

	 Almost never    Sometimes    Often    Nearly always

14.	I drank more than half a bottle of spirits per day (OR 2 bottles of wine OR 15 beers).

	 Almost never    Sometimes    Often    Nearly always

15.	I drank more than one bottle of spirits per day (OR 4 bottles of wine OR 30 beers).

	 Almost never    Sometimes    Often    Nearly always

16.	I drank more than two bottles of spirits per day (OR 8 bottles of wine OR 60 beers).

	   Almost never    Sometimes    Often    Nearly always

Physical & Social History	
Do you have any history of fits, seizures, hallucinations or blackouts?		
Do you have a gambling problem?		
Do you use illicit or prescription drugs?		
If yes, please provide details of which drugs, how much and how often	
	
Have you previously had a major illness or operation?		
If yes, please provide details	
	
Do you have any other significant medical history?		
If yes, please provide details	
	
Do you have hepatitis or HIV?		
Is there a family history of addiction issues?		

If yes, please provide details	

Do you have any employment, housing or finance issues?		
If yes, please provide details	
	
Is there any history of criminality or outstanding legal issues?		
If yes, please provide details	
	
Do you have close friends or family support?		
Do you drive a car or ride a motorbike?		

MENTAL WELLBEING
These questions are used to assess your overall mental health	
Have you ever seen a doctor or psychiatrist for emotional problems or problems with your 'nerves' / anxieties / worries?	
If yes (currently or in the past), please provide details	
Have you ever been given medication for emotional problems with your 'nerves' / anxieties / worries?	
If yes (currently or in the past), please provide details	
Have you ever been hospitalised for emotional problems with your 'nerves' / anxieties / worries?	
If yes, please provide details	
Do you have a current mental health worker, psychiatrist you see for anxiety or depression?	
If yes, please provide details	
Has the thought of ending your life ever been on your mind?	
If yes, please provide details	
Have you ever made a suicide attempt or tried to harm yourself?	
If yes, please provide a list of all previous self-harm or suicide attempts	
Has anyone in your family or a close friend tried to harm themselves or take their own life?	
If yes, please provide details (person, date, method)	
Have you had any recent thoughts of ending your life or harming yourself?	
If yes, when was the last time you had these thoughts?	
If you have current thoughts of ending your life or harming yourself, do you have a plan?
(only answer if you said yes to the previous question)	
If yes, what does that plan involve?	
If you have a plan, have you taken any steps to put this into action?
(only answer if you said yes to the previous question)	
If yes, please provide details	
Do you have thoughts of harming others as well as yourself?	
If yes, please describe who you would harm and what plan you have	
Have you taken steps to put this plan into action?
(only answer if you said yes to the previous question)	
If yes, please provide details	
Do you feel there are important factors preventing you from attempting to harm yourself or take your own life?	
If yes, please describe these factors	

K10 QUESTIONNAIRE
These questions assess a person’s current level of psychological distress	
1. In the past 4 weeks, how often did you feel tired out for no good reason?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
2. In the past 4 weeks, how often did you feel nervous?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
3. In the past 4 weeks, how often did you feel so nervous that nothing could calm you down?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
4. In the past 4 weeks, how often did you  feel hopeless?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
5. In the past 4 weeks, how often did you feel restless or fidgety?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
6. In the past 4 weeks, how often did you feel so restless you could not sit still?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
7. In the past 4 weeks, about how often did you feel depressed? 
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
8. In the past 4 weeks, how often did you feel that everything was an effort?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
9. In the past 4 weeks, how often did you feel so sad that nothing could cheer you up?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	
10. In the past 4 weeks, how often did you feel worthless?
	None of the time	A little of the time	Some of the time	Most of the time	All of the time	

Malnutrition Screening Tool
These questions assess whether you are at risk of malnutrition	
Have you lost weight recently without trying?	Yes / No	
If yes, how many kg?	1-5; 6-10; 11-15; >15; Unsure	
Have you been eating poorly because of a decreased appetite?	Yes / No