Case History No.                                                         Date:     /     / 2007.

Name: _______________________                            Age: ________

Drug Addicted To _____________                             Age of First Use: __________

Years of Use: _________________                            Years of Excessive Use: _____

Quantity of Use: _______________                            Route of Use: _____________

Residing Place:  Village / City                                     Employed / Unemployed.

After How Much Time do you take? : ___________ 

Any Problem After Taking Drug:  Depression / Suicidal Attempt / Confusion / Aggressive

Willing / Unwilling? : _____

Childhood / Adolescent History: _________________________________________

What was the Reaction of the Family: _____________________________________

Did you Experienced Following before the Age of 15 Years:

1)      Poverty 2) Early Parental Loss 3) Extra Marital Affairs of Parents .etc.

Do you want given away this Habit? : __________

Withdrawal Symptoms… when Stopped Drug : _______________________________

Reasons For Taking Drugs :_______________________________________________

Consequences After Taking Drugs:_________________________________________

Who inspired you to Join “NAV JYOTI” ? :__________________________________

Time of Stay in Drug De-Addiction Centre :__________________________________

How Life Has Changed After Joining “NAV JYOTI” ? :________________________

How are you feeling the Environment of the Centre ? : _________________________

Are Curing Methods Helping You ? : _____________

About your Family Members:  ______________ ______________________________

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________________  _______  ______________ ______________________________

________________  _______  ______________ ______________________________

Influenced By Any Family Member For Taking Drugs?

Have you ever lost friends because of your use of drugs?  

Have you ever neglected your family or missed work because of your use of drugs?

Have you ever lost a job because of drug abuse?

Have you ever been arrested?
Have you done any illegal activity in order to obtain drugs?

Have you had medical problems as a result of your drug use:

(e.g., memory loss, weight loss, hepatitis, Sleepless, Jaundice, bleeding, etc.)?

Do you ever feel bad about your drug abuse?

If Any Treatment Before: _______________________________________________

Diagnosis: ____________________________________________________

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