High Risk Assessment

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High Risk Assessment Last Completed: --

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You 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

1. What is your age?

2. Please specify your gender.

Male

Female

Other

3. Do you identify as Aboriginal/Indigenous?

Yes

4. Over the past 3 months, were you released from a correctional facility?

Yes

5. 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)

Yes

6. Over the past 6 months, have you experienced any symptoms of mental illness?

Yes

Please specify the mental illness(es)

Depression

Anxiety disorder

Other: Please specify

Please specify

7. Over the past 30 days, have you intentionally participated in any non-suicidal self-harm behaviours?

Yes

8. Over the past 30 days, have you thought about killing yourself?

Yes

9. Have you ever tried killing yourself?

Yes

10. Have you ever been a victim of abuse?

Yes

Please specify what type of abuse

Physical abuse

Sexual abuse

Emotional abuse

Rather not answer

Other: Please specify

Please specify

LOW RISKS HIGH RISKS

11. Are you currently experiencing chronic pain (pain that lasts or recurs for more than 3 months)?

Yes

Please rate the pain on a typical day. (if you rather not answer this question, please select "N/A")

Please indicate where you experience chronic pain (select all that apply)

Head and neck

Chest and abdomen

Back

Hands and/or feet

Arms

Legs

Other: please specify

Please specify

12. Are you currently living with HIV?

Yes

13. Are you currently living with Hepatitis C?

Yes

14. Over the past 30 days, have you engaged in any of the following behaviours? (select all that apply)

Injecting into an artery

Reusing needles

Driving while intoxicated

None of the above

15. Over the past 30 days, have you witnessed someone overdosing on opioids?

Yes

How many times have you witnessed someone overdosing?

16. How would you assess your own current risk of experiencing an opioid overdose?

No risk

Very low risk

Low risk

Medium risk

High risk

Very high risk

17. Do you have any children?

Yes

Are they currently living with you?

Yes

18. Do you have a pet/pets currently living with you?

Yes

19. Have you set goals for yourself for the near future?

Yes

What do your goals involve?

Physical Health

Emotion Well-Being

Intellectual Enrichment

Life-Work Satisfaction

Social Effectiveness

Spiritual Awareness

Other: Please specify

Please specify

20. Over the past 4 weeks, have you had a significant intimate partner(s)?

Yes

How would you rate the relationship(s) you have with your intimate partner(s)?

LOW RISKS HIGH RISKS

21. How many years of formal education do you have?

Please specify

22. Are you regularly involved in activities that you find meaningful?

Yes

Please Specify the activities

Sports

Hobbies

Employment

Volunteering

Advocacy

Other: Please specify

Rather not answer

Please specify

23. Over the past 30 days, have you been in contact with any of the following people?

Family Members

Friends

None of the above

How often are you in contact with your family members?

How often are you in contact with your friends?

24. Are you satisfied with your current housing situation?

Very satisfied

Satisfied

Neutral

Dissatisfied

Very dissatisfied

Please specify your current housing situation

Please specify

25. 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?

Yes

In the past 6 months, have you used prescription opioids alone?

In the past 6 months, have you injected them?

In the past 6 months, have you used prescription opioids together with any of the following substances?

Benzodiazepines

Stimulants

Alcohol

Marijuana

Don’t know

Rather not answer

When did you last use prescription opioids?

26. In the past 6 months, have you taken street opioids (e.g. heroin or fentanyl)?

Yes

In the past 6 months, have you used street opioids alone?

In the past 6 months, have you injected them?

In the past 6 months, have you used prescription opioids together with any of the following substances?

Benzodiazepines

Stimulants

Alcohol

Marijuana

Don’t know

Rather not answer

When was your last use?

27. In the past 6 months, how many times did you overdose from opioids?

0 time

1 time

2-4 times

5+ times

For these overdoses, how many times have you been in the emergency department?

28. In the past 6 months, have you actively sought out fentanyl/fentanyl analogues?

Yes

29. Are you currently undergoing Opioid Agonist Treatment (OAT)?

Yes

What medication?

How satisfied are you with the treatment?

Over the past 6 months, have you been denied access to OAT?