Overdose Risk Assessment Form
Please complete this assessment to help identify potential risk factors for overdose. Your responses are anonymous and intended for general assessment purposes only.
How often do you use prescription or non-prescription substances that could lead to overdose?
*
Never
Rarely
Sometimes
Often
Very Often
In the past 12 months, have you increased the amount or frequency of your substance use?
*
No change
Slight increase
Moderate increase
Significant increase
How confident are you in your ability to avoid unintentional overdose?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
How often do you use substances alone?
*
Never
Rarely
Sometimes
Often
Always
Do you know the signs and symptoms of an overdose?
*
Yes
Somewhat
No
How easy would it be for someone to assist you in case of an overdose?
*
Very difficult
1
2
3
4
Very easy
5
1 is Very difficult, 5 is Very easy
Rate your access to emergency support or overdose reversal medication (such as naloxone):
*
1
2
3
4
5
Have you experienced any recent changes in your physical or mental health that concern you?
*
No
Yes, minor changes
Yes, significant changes
How often do you combine multiple substances (including alcohol, prescription, or non-prescription drugs)?
*
Never
Rarely
Sometimes
Often
How likely are you to seek help or support if you feel at risk for overdose?
*
Not likely
1
2
3
4
Very likely
5
1 is Not likely, 5 is Very likely
Submit Assessment
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