CHEMICAL DEPENDENCY ASSESSMENT FORM

• EASILY AGITATED? EXTREMELY DEFENSIVE?
• DEFIANT WHEN QUESTIONED OR CHALLENGED ABOUT GENERAL QUESTIONING?
• ENTITLED?
• PROBLEMS WITH IMPULSE CONTROL?
• ISOLATING?
• EXHIBITING RAGE OR INORDINATE ANGER?
• SUDDENLY STRUGGLING ACADEMICALLY?
• EXPERIENCING RAPID WEIGHT LOSS OR GAIN?
• MISSING PRACTICE, WORK, AND COMMITMENTS OFTEN?
• DISAPPEARING DURING PRACTICE OR WORK OFTEN, TO THE LOCKER ROOM OR RESTROOM?
• RUMORED TO BE PARTYING EXCESSIVELY?
• HAVING EXCESSIVE RELATIONSHIP ISSUES?
• EXPERIENCING LEGAL ISSUES?
• BLAMING OTHER PEOPLE, PLACES AND THINGS FOR THE WAY THEIR LIFE IS?

ONCE YOU HAVE DETERMINED THERE MIGHT BE A SUBSTANCE ABUSE ISSUE, LOOK FOR THE FOLLOWING SYMPTOMS

Alcohol Abuse

Anxiety or Jumpiness

Sweating excessively

Nausea or Vomiting

Tremors

Fatigue

Irritability

Depression or frequent sadness

Marijuana Abuse

Lethargy

Red Eyes

Paranoia

Mood Swings

Panic Attacks

confusion or psychosis

PARAPHERNALIA: rolling papers, small plastic baggies and stash cans (film canisters, small glass vials, mint tins), pipes, bongs, roach clips, room deodorizers and incense.

Opiate Abuse

Withdraw symptoms occur every few hours unless drug is accessible. They include:

Dehydration

Irritability

Rage

Sweating

Vomiting

Diarrhea

inability to be still

severe pain in legs

PARAPHERNALIA: needles, Rx Pill bottles, or supplement bottles, small pieces of crumpled foil (usually with black burn marks), empty heroin "balloons"

Steroid Abuse

Rapid Muscle Gain

Uncontrolled aggression and violent behavior

Mood Swings

Sense of invincibility (may even be associated with delusions)

Paranoid Jealousy

Hair Loss

PARAPHERNALIA: needles, creams and ointments, supplement bottles

Stimulant Abuse

Manic Behavior. Inability to sit still

"Chewing" inner jaw

Runny Nose, chronic cold or sinus problems

nose bleeds

dry mouth or chapped lips

bad breath

rapid weight loss (associated with loss of interest in food or sleep)

excessive talking-changing subjects frequently

Irritable or Argumentative

Nervous

PARAPHERNALIA: small spoons, razor blades, mirror, little bottles of white powder, and plastic metal or glass straws.