Patient Name(Print):
*
Patient Signature:
Date:
*
/
Month
/
Day
Year
Date
Type your initials below to verify you understand that combining buprenorphine with alcohol or other sedating medications (such as Valium, Librium, Ativan, Xanax, Klonopin, gabapentin) is dangerous.
*
Type your initials below to verify that you understand you are required to have 2 random pill counts a year and that you will provide a phone number that you can be reached at. You also state you understand that non-compliance with your random pill counts may result in dismissal from the treatment program.
*
FEMALES ONLY: Type your initials below to verify you understand that you MUST use a reliable form of birth control and agree to random pregnancy tests. The risk of treatment during pregnancy include miscarriage and Neonatal Abstinence Syndrome.
Patient name(Print)
*
Patient Signature:
Date:
*
/
Month
/
Day
Year
Date
Patient Name:
*
DOB:
*
Which of the following have you used either recently or in the past? Check all that apply.
*
Methamphetamines (speed, crystal)
Cocaine
Cannabis (marijuana, pot)
Narcotics (heroin, oxycodone, methadone, etc.)
Inhalants (paint thinner, aerosol, glue)
Hallucinogens (LSD, mushrooms)
Tranquilizers (valium)
Other
How often have you used these drugs?
*
Monthly or less
Weekly
Daily or almost daily
Have you used drugs other than those required for medical reasons?
*
Yes
No
Do you abuse more than one drug at a time?
*
Yes
No
Are you unable to stop using drugs when you want to?
*
Yes
No
Have you ever had blackouts or flashbacks as a result of drug use?
*
Yes
No
Do you ever feel bad or guilty about your drug use?
*
Yes
No
Does your spouse (or parents) ever complain about your involvement with drugs?
*
Yes
No
Have you neglected your family because of your use of drugs?
*
Yes
No
Have you engaged in illegal activities in order to obtain drugs?
*
Yes
No
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
*
Yes
No
Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?
*
Yes
No
Have you ever injected drugs?
*
Never
Yes, in the past 90 days
Yes, more than 90 days ago
Have you ever been in treatment for substance abuse?
*
Never
Currently
In the past
Patient:
*
DOB:
*
Date:
*
/
Month
/
Day
Year
Date
E mail address (Required if you have one):
example@example.com
My goal with treatment is:
*
How many years have you abused opiates?
*
The medications I take that are prescribed to me are:
*
The medications/street drugs I take that are not prescribed to me are:
*
I have recently used: (Check all that apply)
*
Nerve pills
Pain pills
Neurontin
Alcohol
Headache meds
Tobacco products recently used: (Check all that apply)
*
Cigarettes
Chewing tobacco
Dip
E-cigarettes
Have you ever used IV drugs?
*
Yes
No
If you circled yes, what did you use?
Have you ever had any kind of drug treatment before?
*
No
Yes
If you circled yes, what kind of treatment?
When did you have treatment?
Have you ever tried to hurt yourself or attempted suicide?
*
Yes
No
Have you ever thought about hurting yourself or attempting suicide?
*
Yes
No
Do you currently have any legal issues/ charges against you?
*
Yes
No
Have you ever been to jail for any reason?
*
Yes
No
Why?
Have you lost custody of your children?
*
Yes
No
When?
FEMALES ONLY: What is your method of birth control? (required)
Last menstrual period date:
/
Month
/
Day
Year
Date
Patient Signature
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Please read each option carefully and check them as you go if you agree to the following statements:
*
Authorize New Path Medical Center Staff at the address above to disclose my treatment for opioid dependence to employees of the pharmacy specified below. Treatment disclosure most often includes, but may not be limited to, discussing my medications with the pharmacist, and faxing/calling in my buprenorphine prescriptions directly to the pharmacy.
Agree to purchase all SUBOXONE, SUBUTEX, and any other medications related to my treatment from the pharmacy specified below.
Agree not to use any pharmacy other than the one specified below for the duration of my treatment with the physician specified above, unless specific arrangements have been made with the physician.
Agree to make payment arrangements with the pharmacy specified below in advance of treatment, SO that my buprenorphine prescriptions can be filled and either delivered to the office address given above or picked u] by employees of the same.
Patient Signature
Date
*
/
Month
/
Day
Year
Date
The pharmacy I would like to have my medication sent to is:
*
Pharmacy Address (City and State is fine, unless there are multiple locations for that town)
*
Pharmacy Phone Number:
*
Name:
*
DOB:
*
Date:
*
/
Month
/
Day
Year
Date
Chief Complaint: What is the reason for your visit today( please describe problem in detail)
*
Past Medical History: Please check all that apply to you
*
Arthritis
Epilepsy/seizures
Psychiatric disease
Cancer
Heart problems
Stroke
Depression
Heart Surgery
High blood pressure
Thyroid
None
Other
Previous Surgeries: Please list past surgeries with approximate date
Please check any vaccinations that you have recently had or are up to date on:
Influenza
Pneumococcal
Tetanus
Shingle
Hepatitis B
Hepatitis A
Please list all medications that you are taking with dose and frequency:
Preferred Pharmacy:
*
City:
*
Allergies: please list any allergies you have:
*
Do you smoke?
*
Yes
No
If yes, how many cigarettes/day?
Do you drink alcohol?
*
Yes
No
If yes, how much/week?
Do you consume caffeine?
*
Yes
No
If yes, how many cups or cans/week?
Do you use recreational drugs?
*
Yes
No
If yes, what type and frequency?
Are you on a special diet?
*
Yes
No
If yes, please describe:
Number of sexual partners in the last 12 months?
*
Do you have sex with:
Males
Females
Both
Is your father living or deceased; What kind of health problems does/did he have?
Is your mother living or deceased; What kind of health problems does/did she have?
Is your brother living or deceased; What kind of health problems does/did he have?
Is your sister living or deceased; What kind of health problems does/did she have?
Date of last menstrual period:
/
Month
/
Day
Year
Date
Date of menopause:
/
Month
/
Day
Year
Date
Number of pregnancies:
Miscarriages:
Abortions:
Patient Name:
*
Date:
*
/
Month
/
Day
Year
Date
Do you currently have any of the following symptoms or conditions TODAY? (Check all that apply)
*
Decline in health
Abdominal pain
Constipation
Joint pain
Muscle cramps
Weakness
Weight gain
Chest pain
Diarthea
Jaundice
Weight loss
Palpitations
Cold intolerance
Fatigue
Weakness
Dizziness
Head injury
Headaches
Blurry vision
Suicidal thoughts
Suicide attempts
Difficulty starting stream (urinating)
Excessive urination
Fatigue
Goiter
Heat intolerance
Increased thirst
Neck pain
Sweats
Thyroid trouble
short of breath
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