Cell: +1 (714) 252-6636


A pre-screening document.

A pre screening document is a set of questions set by an interviewer in order to get information from the targeted group of people or individual. This is mostly experienced in hospitals where patients seeking medical care are advised to fill in a form, describing their health history and their current health condition. The purpose of a pre-screen document or form is to enable doctors with diagnosis or what the patient needs for treatment. In a rehabilitation centre, for example a drug addict wants to quit using drugs, the doctor asks the patient to fill in a form describing some of the drugs the addict uses, how long they have used them and to what degree. These are some of the information details present in a pre screen document. Drug addiction is one of the leading fatal problems (Bier, 1962) reigning most of the youth today, some fight to get out of it but the environment or due to peer influence they find it hard to stop (Barnard, 2007). But some take the most difficult step and they decide to openly declare their addiction; they join rehabilitation centres where they are taken through step by step process in order to recover. As they join the rehabilitation centres, they are required to go through a pre screening interview either orally or via filling a form so as to give the counsellors and doctors a go ahead of what to expect and through that they can decide which path they can take towards recovery.

Fill in the following detail.

Full name:

Sex/ age:

Marital status:

Contacts/ email address:

As Drug Rehabilitation centre the knowledge about our client’s health history and his current health status is our concern. For the questions asked below a tick if the answer is yes if no leave the box blank. For the information you are required to write the answers please do. Pay attention to what is asked and fill in the correct information.

Which kind of drug(s) do you use? Yes or No






When did you start using the drug(s)?

For how long have you used the drug(s)?

How many times in a day do you use the drug(s)?

How did you get introduced to the drug(s)?

How do the drug(s) affect your body function when used and when not used?

What made you decide to want to quit using the drug(s)?

Please indicate any diseases that have affected you since you started using the drug(s) and how many times you have sought medical attention at a clinic, dispensary or hospital as a result of the same (Brick, 2008).

How has the drug(s) affected your social life, e.g. family, partners or friends (Barnard, 2007)?

Have you had cases of the following diseases or been diagnosed with the following disorders?

Yes or No

Whooping cough



Lung cancer

If you suffer any of the following diseases or have one of the conditions above, what medical action have you taken?

Have you had cases of hallucinations, seizures, and episodes of deliriums?

What kind of food does your meal consist of is it balanced or has more of carbohydrates or proteins or fats, if any of the above, please indicate and any other additional information describing your eating habits.

What is your personal description of drug addiction and what is your personal opinion about it?

What do you hope to achieve at the end of this rehabilitation program?

When all answers are fully and correctly indicated the patient is to sign his name and signature. The medical officer or psychiatrist in-charge should also sign the document.

Above is chart that is used to learn about the addicted patient and through the information doctors and counsellors have a basis of what to do.


Barnard, M. (2007). Drug addiction and families. London: Jessica Kingsley Publishers.

Brick, J. ( 2008). Handbook of the medical consequences of alcohol and drug abuse (2nd ed) New York: Haworth Press.

Bier, W. C.(1962). Problems in addiction: alcohol and drug addiction. New York: Fordham University Press.

Looking for a similar assignment? Get help from our nursing qualified experts!

Order Now

Open chat
Get help
You can now contact our live agent via whatsapp! ping +1 (714)-584-4466.
You will get plagiarism free custom written paper