High Risk Assessment 29 High Risk Assessment Last Completed: -- Page 1 of 3You can lower your risk of overdose by learning about risk factors and setting relevant goals. Use the risk emulator to see how changing your answers can impact your risk of overdose. Your risk emulator score will not replace your HRA score- it is simply a way to better understand your risk of overdose. LOW RISKS HIGH RISKS LOW RISKS HIGH RISKS 1. What is your age?Please select0-59 years old60+ years old 2. Please specify your gender.MaleFemaleOther3. Do you identify as Aboriginal/Indigenous?YesNo4. Over the past 3 months, were you released from a correctional facility?YesNo5. Over the past year, have you experienced a stressful life event that has disrupted your life in a major way? (such as death of spouse or close family member, divorce, detention, major injury or illness or being fired at work)YesNo6. Over the past 6 months, have you experienced any symptoms of mental illness? YesNoPlease specify the mental illness(es)DepressionAnxiety disorderOther: Please specifyPlease specify7. Over the past 30 days, have you intentionally participated in any non-suicidal self-harm behaviours?YesNo8. Over the past 30 days, have you thought about killing yourself?YesNo9. Have you ever tried killing yourself?YesNo10. Have you ever been a victim of abuse?YesNoPlease specify what type of abusePhysical abuseSexual abuseEmotional abuseRather not answerOther: Please specify Please specifyNext LOW RISKS HIGH RISKS 11. Are you currently experiencing chronic pain (pain that lasts or recurs for more than 3 months)?YesNoPlease rate the pain on a typical day. (if you rather not answer this question, please select "N/A")0/10 (no pain)1/102/103/104/105/106/107/108/109/1010/10 (worst possible pain)N/APlease select...Please indicate where you experience chronic pain (select all that apply)Head and neckChest and abdomenBackHands and/or feetArmsLegsOther: please specifyPlease specify12. Are you currently living with HIV?YesNo13. Are you currently living with Hepatitis C?YesNo14. Over the past 30 days, have you engaged in any of the following behaviours? (select all that apply)Injecting into an arteryReusing needlesDriving while intoxicatedNone of the above15. Over the past 30 days, have you witnessed someone overdosing on opioids? YesNoHow many times have you witnessed someone overdosing?16. How would you assess your own current risk of experiencing an opioid overdose?No riskVery low risk Low riskMedium riskHigh riskVery high risk17. Do you have any children?YesNoAre they currently living with you?YesNo18. Do you have a pet/pets currently living with you?YesNo19. Have you set goals for yourself for the near future?YesNoWhat do your goals involve?Physical HealthEmotion Well-BeingIntellectual EnrichmentLife-Work SatisfactionSocial EffectivenessSpiritual AwarenessOther: Please specifyPlease specify20. Over the past 4 weeks, have you had a significant intimate partner(s)?YesNoHow would you rate the relationship(s) you have with your intimate partner(s)?Please selectVery goodGoodNeutralBadVery badUnsure BackNext LOW RISKS HIGH RISKS 21. How many years of formal education do you have? Please selectNoneElementary/middle school (up to Grade 9)Some high school (Grade 10, 11)High school certificate (completed Grade 12)Post-secondary (e.g. technical school, trade school, college, university)Other: Please specify Please specify22. Are you regularly involved in activities that you find meaningful?YesNoPlease Specify the activitiesSportsHobbiesEmploymentVolunteeringAdvocacyOther: Please specifyRather not answerPlease specify23. Over the past 30 days, have you been in contact with any of the following people?Family MembersFriendsNone of the aboveHow often are you in contact with your family members?Please selectRegular contactSporadic contactRather not answerHow often are you in contact with your friends?Please selectRegular contactSporadic contactRather not answer24. Are you satisfied with your current housing situation?Very satisfiedSatisfiedNeutralDissatisfiedVery dissatisfiedPlease specify your current housing situationPlease selectStable housing (owning or renting house/apartment)Non-stable housing (hotel, SRO, temporary stay at someone else’s house/apartment, etc.)ShelterOn the Street (indoor public place, bus or train station, abandoned building, etc.)Institution (detox, nursing home, jail or prison, hospital, treatment or recovery residence, etc.)Other: please specifyRather not answerPlease specify25. In the past 6 months, have you taken prescription opioids (e.g. codeine, morphine, oxycodone), without a doctor’s prescription or in larger doses than prescribed, to get high, buzzed, or numbed out?YesNoIn the past 6 months, have you used prescription opioids alone? Please selectYesNoRather not answerIn the past 6 months, have you injected them?Please selectYesNoRather not answerIn the past 6 months, have you used prescription opioids together with any of the following substances?BenzodiazepinesStimulantsAlcoholMarijuana Don’t know NoRather not answer When did you last use prescription opioids?Please select0 - 7 days ago8 - 30 days agoMore than a month ago26. In the past 6 months, have you taken street opioids (e.g. heroin or fentanyl)?YesNoIn the past 6 months, have you used street opioids alone?Please selectYesNoIn the past 6 months, have you injected them?Please selectYesNoIn the past 6 months, have you used prescription opioids together with any of the following substances?BenzodiazepinesStimulantsAlcoholMarijuana Don’t know NoRather not answer When was your last use?Please select0 - 7 days ago8 - 30 days agoMore than a month ago27. In the past 6 months, how many times did you overdose from opioids?0 time1 time2-4 times5+ timesFor these overdoses, how many times have you been in the emergency department? Please select1 time2 times3 times4 times5 times6 times7 timesNone28. In the past 6 months, have you actively sought out fentanyl/fentanyl analogues?YesNo29. Are you currently undergoing Opioid Agonist Treatment (OAT)? YesNoWhat medication?Please selectBuprenorphine/naloxone (Suboxone)MethadoneSlow release oral morphineInjectable hydromorphone (Dilaudid)Diacetylmorphine (Prescription heroin)How satisfied are you with the treatment?Please selectVery satisfiedSatisfiedNeutralDissatisfiedVery dissatisfiedOver the past 6 months, have you been denied access to OAT?Please selectYesNoBackNEXT
