SGP_substance_abuse


1. Identification

GP code

Startdate of consultation week (monday)

Format: mm-dd-yyyy

Sex patient
Agegroup patient
< 25 year
25 - 34 year
35 - 44 year
45 - 54 year
55 - 64 year
>= 65 year

2. Previous and current treatment

Does the patient currently also receive treatment elsewhere for problems of substance use?
Yes
No
Unknown
Did the patient already receive treatment for substance use problems in the course of his life, by you or by another caregiver?
Yes
No
Unknown
Does the patient currently receive methadone or buprenorphine as substitution therapy?
Yes
No
Unknown

3. Substances that are currently causing problems

What psychoactive substances are currently causing problems to the patient?
Alcohol
Hypnotics or sedatives
Opiates
Cocaine or crack
Stimulantia other than cocaine
Cannabis (marijuana, hash,...)
Hallucinogens (LSD, ketamine)
Volatile inhalants
Other:

4. Primary substance for which the patient receives treatment

Primary substance leading the patient to start this treatment
During this last month, at what frequency was this primary substance used?
Not used during the last month
1 day per week or less
2 - 3 days per week
4 - 6 days per week
Daily
Unknown
At what age (approximately) was this primary substance used for the first time?

5. Professional activity

Is the patient currently or until recently (≤ 4 weeks) professionally active?
Yes
No
Unknown