Substance Abuse Recovery Assessment Form |
हिन्दी
Name *:
Father’s Name *:
Village/Ward *:
District *:
Select
Ambala
Bhiwani
Charkhi Dadri
Faridabad
Fatehabad
Gurugram
Hisar
Jhajjar
Jind
Kaithal
Karnal
Kurukshetra
Mahendragarh
Mewat
Palwal
Panchkula
Panipat
Rewari
Rohtak
Sirsa
Sonipat
Yamunanagar
Police Station *:
Mobile Number
ID Number (if any)
Simple Progress Evaluation
(A) Abstinence from Substance Use
Have you consumed any substances in the last 15 days? *
Select
Not at all (5)
Once or twice (4)
Once a week (3)
Several times (2)
Daily (1)
Do you feel cravings for the substance? *
Select
Not at all (5)
Occasionally (4)
Sometimes (3)
Often (2)
Very frequently (1)
(B) Daily Routine & Responsibilities
Are you able to manage work/studies/family responsibilities? *
Select
Completely (5)
Mostly (4)
Sometimes (3)
Rarely (2)
Not at all (1)
How is your sleep quality? *
Select
Very good (5)
Fairly good (4)
Sometimes disturbed (3)
Poor (2)
Very disturbed (1)
(C) Social & Family Relationships
Have your relationships with family and friends improved? *
Select
Significantly improved (5)
Somewhat improved (4)
No change (3)
Slightly worsened (2)
Much worse (1)
Are you receiving support from your family? *
Select
Very supportive (5)
Fairly supportive (4)
Neutral (3)
Little support (2)
No support (1)
(D) Health & Rehabilitation Efforts
Do you feel any improvement in your physical health? *
Select
Completely recovered (5)
Significant improvement (4)
Slight improvement (3)
No major change (2)
Health worsening (1)
Are you attending counseling or rehabilitation programs? *
Select
Regularly (5)
Occasionally (4)
Rarely (3)
Only once or twice (2)
Not at all (1)
Submit
