BEATING HEROIN

AN ADD DIAGNOSTIC QUESTIONNAIRE TREATMENT RECORD FOR ADOLESCENTS ADULTS
(ADD = Attention Deficit Hyperactivity Disorder = Focus/Activity Disorder Distress)
Dr Neil Beck Fax : 61(08)9386 3333 Phone: 9386 8873 E-mail: [email protected]
Web Site: HeroinAddictionNaltrexone.com
Postal Address: 3/105 Broadway, Nedlands 6009 Western Australia

1. How Did You Get On In Primary School?

(a) Did you have difficulties with learning? If so, what were some of the difficulties that you had?
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(b) Did you have behaviour which was disturbing to your teachers or to your classes? If so, what were some of those behaviours? How did your teachers react to this behaviour? What did they do to you?
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2. How Did You Get On In High School?

(a) Did you have learning difficulties? If so, what learning difficulties? Were there some subjects you were good at and others you were bad at? If so, which subjects?
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(b) Did you have behaviour which upset your teachers or disturbed your classes? If so, what were the problems? How did your teachers react to this behaviour? What did they do to you?
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(c) Were you away from school a lot? For what reasons? What did you do on the days you didn't go to school?
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(d) Which High Schools did you attend?
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(e) In what year of school did you leave? During term or at the end of term or at the end of the year? Why did you leave?
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3. At what time do you prefer to go to bed and at what time do you prefer to get up?
Do you have difficulty going to sleep or getting up?
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4. Are you a very active person? Do you tend to have several things on the go at once? Do you start new things before you finish what you are already doing?
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5. If you get interested or involved in something, or focused on something, do you tend to get so wrapped up in it that you overdo it, have difficulty in switching off from it, and neglect other things?
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6. Do you often get very anxious, restless, impatient, driven, unable to wait, or to wait your turn and then become overcommited, exhausted, anxious or agitated?
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7. Do you sometimes find it hard to get motivated, to get started? Do you sometimes procrastinate and get behind in things?
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8. What problems, if any, have you had in your employment?
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9. What problems, if any, have you had in your relationships?
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10. What forms of unhappiness and distress, if any, do you experience?
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11. Do you, or have you in the past, abused any drugs or other substances?
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12. If you use a small to moderate amount of amphetamines (1-3 points or .1 to .3 gms), what effects does it have on you? If you use half to one gram, what effects does it have on you?
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13. Are there any foods, confectionery, drinks or other substances that seem to make you (or anyone else in your family) sleepless, restless, overactive, irritable or aggressive? Are you allergic to gluten or dairy products? Do you eat a lot of junk food. ______________________________________________________________________________________________
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14. Have you ever been fined or charged for any offences? If so, what offences?
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15. Have you ever seen a psychologist, a psychiatrist or any other doctor or counsellor about any psychological or social problems? If so, what was their diagnosis of your problems? What treatment did they recommend or give to you? What were their ______________________________________________________________________________________________
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16. What personal or extended family history do you have, of substantial artistic talent, uniqueness or originality, substance abuse, other forms of addiction (such as gambling, workaholism, spending, excitement, the internet, sex or exercise) depressio ______________________________________________________________________________________________
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FOR THE DIAGNOSTICIAN TO COMPLETE
Differential Diagnosis (a) Misbehaviour due to high IQ and boredom: ______________________________________
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(b) Profound Anxiety:_________________________________________________________________________
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(c) Manic Depressive Disorder:__________________________________________________________________
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(d) Other Comorbidity e.g. Dissociative or Personality Disorder, Tics, Dyskinesia, Tourette's__________________
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(e) Schizophrenia or Psychosis that may be aggravated by Stimulant Therapy_____________________________ ______________________________________________________________________________________________
(f) Drug Alcohol Abuse______________________________________________________________________ ______________________________________________________________________________________________
Diagnosis, Treatment Plan (Including Mood Stabilisers, SSRI's, Stimulant Therapy, Diet EEG Biofeedback and Diagnosis Management of Comorbid Conditions) Initial Prescriptions____________________________
_____________Date:_____________________________________________________________________________
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