Controlled Substances Questionnaire
Name
*
First Name
Last Name
Medicine name and dose
*
How often do you take it?
*
Is it working adequately?
*
Yes
No
If no, please explain.
With what symptom(s) does it help the most?
*
Are you having any side effects?
*
Yes
No
If yes, what side effects are you having?
Where do you store the medicine?
*
Do you use the medicine for anything other than the use for which is was prescribed?
*
Yes
No
If yes, for what?
Have you ever shared this medicine with, or sold it to, others?
*
Yes
No
I understand that I will not be able to obtain a refill without an office visit if more than six months have elapsed since the date of the last refill.
*
Yes
No
Signature (by signing below I attest that my answers to the above questions are accurate)
*
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