sample_2.txt

MEDICAL SUMMARY REPORT----SAMPLE---SAMPLE---SAMPLE
Personal History
Joe is a 32 year-old, white male. Joe has been using methamphetamine for the past eight years, smoking
the drug 3-6 per week. He is the middle of three siblings. He has an older sister and a younger brother.
Joe was born and raised in Arkansas. He moved to the West Coast at the age of 20. He was thrown out
of the family home after getting to a confrontation with his brother. Joe said he was abused at a young
age but did not want to elaborate on the kind of abuse he suffered. From time to time, Joe said he gets
angry at the slight inconvenience which cause him go into rants and outbursts which last for 5 – 10
minutes at a time. He said this started happening right before he became a teenage and occurred ever
since. He said these outbursts have caused a strained on many of the relationships he had developed
over his lifetime. They have caused him to be suspended from school, lose jobs, be homeless, and
destroyed other personal relationships. As a result, Joe said he has only two friends, Bob and Lisa, who
are neighbors who live close to him.
Physical Health
Joe appears older than his stated age. He has had open sores on various parts of his body in the past
because he has not always bathed regularly. However, now he seems to be taking care of himself and
was dressed relatively well for the setting. He was cooperative in the interview answering all questions
politely. Although today, his memory showed slight signs of impairment. His mood was both anxious and
defensive as result of his diagnosis.

Drug History and Current Pattern of Use
Joe said he first began experimenting with drugs at the age of 12. He drank alcohol every weekend and
smoked marijuana on an almost daily basis throughout his teens.
At 20 Joe told me he began drinking heavily and experimenting with Ecstasy. At 24, he was introduced to
methamphetamine that became his sole drug of choice, in addition to having an occasional drink. He
said he would smoke it 3-6 times a week. However, over the last 5 years he has been trying to stop his
drug use by and has checked himself into drug rehab several times. Although he has done this, he has
not managed to stay clean consistently. During his clean times when he has not done
methamphetamine, Joe has smoked cigarettes to cope with his struggle.
Substance Abuse Treatment History
When he first started out, he was in recovery at a center in California for about a month five years ago.
Once after being arrested in New Jersey for possession of methamphetamine, he entered a local detox
center. At that time, he successfully completed its twenty-one day Rehabilitation Program. He did not
follow up with aftercare or NA meetings. After testing positive for methamphetamine at probation, Joe