› Medical information • A complete medical history for the client should be obtained through client and collateral report and through record review.
Information should include current and past illnesses, injuries, hospitalizations, and surgeries, as well chronic illnesses and disabilities. The social worker should gather information on treatments that were or are being provided, as well as information on pain management for any current medical concerns. If injuries are reported, the cause of injury should be noted. For clients seeking assistance for mental health concerns, medical causes of mental health issues should be evaluated
Reasons for use: The client might be able to identify when and why substances are used. For example, some clients might use substances while in social situations or when they wish to relax, while others might use in isolation or to improve mood or decrease anxiety. Collaterals close to the client might have additional perspectives as to the client’s patterns of use or triggers for use