CENTRAL REGISTRY OF DRUG ADDICTS
RECORD SHEET
Note: Tick (✔) correct box for multiple-choice questions
1. Date of Contact:
2. Source of Report:
day
month year
Dept./Agency
3. For Treatment Agencies only - Type of Contact :
4. Name (in Chinese characters; if non-
on-Chinese, in English)
1 Application
Leave blank :
Appendine B
IN CONFIDENCE
Office/Branch
2 Admission
Leave blank:
6. Alias/nickname (in Chinese characters; if non-Chinese,
in English)
8. Identity Card No.:
I-II-I
5.
-------
7. Leave blank:
9. Sex:
1 Male
10. Date of Birth: Give Western Calendar, if not available give Lunar Calendar
mmm
☐ ☐
2 Female
day
month
year
Estimated age
Cycle/Animal
Lunar Month
11. Place of Birth:
12. Native Place:
|1|Hong Kong
province(省)
2 Outside Hong Kong
leave blank:
3 Unknown
(in Chinese characters)
city ()/yuan hsiang(鄉)
13. schooling:
1
None
2 Yes
3
Unknown
14. Vocational Training:
1
None
(if yes, specify no. of years)
2
Yes
(if yes, specify no. of years)
3
Unknown
15. District of Residence:
1 Hong Kong Island (including Ap Lei Chau) 2 Kowloon Peninsula
3 New Kowloon (north of Boundary Street)
16. Primary drug of abuse over last four weeks (✅one)
1 Opium
2 Heroin
3 Morphine
4 Methadone
5 Amphetamine
6 Barbiturate
7 None
8 | Unknown
9 Other
(specify)
4
N. T. including outlying islands
5 Marine (floating population)
[6] Unknown
17. Other drug(s) of abuse over last four weeks
one or more)
1 Opium
2 Heroin
3 Morphine
4 Methadone
5 Amphetamine
18. Usual method of taking primary drug over last four weeks (✅one)
1 Injection
[2] Smoking (through cigarettes or pipe e.g. ack-ack gun)
Fume inhaling (e.g. chasing the dragon)
4Oral ingestion
19. Age first used illicit drug :
20. Did illicit drug use begin in Hong Kong?
21. Previous Addiction Treatment?
22. Previous conviction?
6 Barbiturate
7 None
8 Unknown
9 Other
(specify)
5 None 6 Unknown 7 Other
(specify)
Unknown
Yes
2 No
Yes
2 No
3 Unknown
Yes
2 No
3 Unknown
23. Lawfully employed over last 4 weeks?
Yes
2 No
3 Unknown
DO NOT WRITE BELOW THIS LINE
Tick one:
Only for Corrections:
1
Register No.
Date Received
2 3 4 5
Correction Code
Case Number
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