PRO System

PRO
PAKISTAN RECOVERY OASIS
Addiction Treatment & Psychological Services
Patient's Name:
Father's Name:
Admission Date:
I.D. No.:
Age:
CNIC No.:
Guardian:
Relation:
Drug:
Contact:
Marital Status:
Prev Admissions:
Address:
Complaint:
History:
General Physical Examination:
Vitals
Resp BP
GIT Pulse
CVS Temp
CNS R/R
BSR Weight

Drug Abuse Screening Test, DAST-10

# Question Yes No
1 Have you used drugs other than for medical reasons?
2 Do you abuse more than one drug at a time?
3 Are you unable to stop abusing drugs when you want to?
4 Have you ever had blackouts or flashbacks?
5 Do you ever feel bad or guilty about your drug use?
6 Does your spouse/parents ever complain about your drug use?
7 Have you neglected your family because of drugs?
8 Have you engaged in illegal activities to obtain drugs?
9 Have you ever experienced withdrawal symptoms?
10 Have you had medical problems due to drug use?

Consent Form / اجازت نامہ

مریض کا نام: ولدیت: عمر:

شناختی کارڈ: رابطہ نمبر: پتہ:

میں اس بات کی تصدیق کرتا/کرتی ہوں کہ مجھے نشے کی بیماری، اس کے اثرات، علاج کے تمام مراحل... (Full Consent Text Restored)

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مریض کے دستخط

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والد/سرپرست کے دستخط