MAT INITIAL PATIENT SCREENING

INITIAL PATIENT SCREENING
Patient Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Zip
Driver's License #
State
(Please provide for photocopy)
Height
Weight
Eye Color
Sex: M

F
Age
SS #
Phone
Marital Status
Ethnic Group
Prescription plan name (If applicable)
Card Number
(Please provide for photocopy)
Emergency Contact Name
Relationship
Address

Address

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone
Work Phone
What is/was your primary drug of choice?
At what age did you first use?
Total years of opiate use
current cost per day
Date/time/drug last used

MonthDayYear
Date
# of times per day
What other drugs are you using?
Describe any previous substance abuse treatment
Do you have any outstanding warrants or legal problems?NoYes
Are your currently using any illegal substances?
What prescription medications are you currently taking?
For what purpose are you taking this medication?
What is the prescribing doctor's name and phone number?
How did you first learn about Comp Serv Health Resources ? (If from a current patient, please provide that patient's name):
This is a fill in the blanks field. Please add appropriate blank fields and text.
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Date

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Date
THE GERWE ASSESSMENT FOR BEHAVORIAL HEALTH
Please answer each question by placing an "X" in the appropriate box. 1. At present, during a 24 hour period of time, in a typical day, which of the following "feelings" seem to occur to you the most often?
AngerFearSadnessShameLoneliness
2. Approximately what percentage, or how much of the time, in a atypical day, do you feel the feeling you have named
Less than 25255075100
3. When you experience the feeling you have named, do you think of

the presentthe pastthe futurethe present and the pastthe present and the future
4.Can you remember your age when you first experienced the feeling you have named- - your first memory of this
feeing?

Ages 1 thru 5Ages 3 thru 12Ages 12 thru 20Ages 20 thru 40Ages 40 thru 80
5.When you experience the feeling you have named, which of the following behaviors is most likely to occur?

Isolating, withdrawal, avoidanceActing, pretending, hiding feelingsVerbal aggression or verbal abusePhysical aggression, physical abuse or violent actionNone of the above
6.When you experience the feeling you have named, which of the following behaviors is most likely to occur?

Any form of self abuseA behavior that you believe to be dishonest
CompServ Health Resourees comprehensive

High-risk, life-threatening behaviorsDestruction of objects, property, possessionsNone of the above
7. When you experience the feeling you have named, which of the following behaviors is most likely to occur?

Pre-occupation with foodre-occupation with moneyPre-occupation with sexPre-occupation with controlNone of the above
8. When you experience the feelings you have named, which of the following behaviors is most likely to occur?

Pre-occupation with suicidePre-occupation with fire, explosives and weaponsPre-occupation with collecting, hiding or hoarding objectsPre-occupation with a person, celebrity, group, or placeNone of the above
When you experience the feelings you have named, which of the following behaviors is most likely to occur?

Fantasizing about deathFantasizing about revenge or retaliationFantasizing about sex or powerFantasizing about being another person or being in a different place or circumstancesNone of the above
When you experience the feeling you have named, which of the following behaviors is most likely to occur?
Adjusting your behavior to become the center of attentionAdjusting your behavior to avoid the attention of othersAdjusting your behavior to please, manipulate or control othersAdjusting your behavior to langer othersNone of the above
When you experience the feeling you have named, which of the following behaviors is most likely to occur?

Attempts to "hide" in a specifiec place or placesAttempts to "escape" or run from the situationAttempts to disguise yourself in some wayAttempts to control a situation, a place or a groupNone of the above
12. If you have named a behavior or behaviors that have developed into a repetitive pattern in relation to the feeling you have named, can you remember the age in your life that the feeling/behavior combination or combinations first occurred?

Ages 1 thru 5Ages 5 thru 12Ages 12 thru 20Ages 20 thru 40Ages 40 thru 80
13. Was this pattern or patterns of behavior in existance

Prior to age 6 with no use of mood-altering substancesPrior to age 12 with no use of mood- altering substancesPrior to first use of mood-altering substances
Prior to addictive use of mood-altering substancesBegan or coincided with first use and onset of addiction to mood-altering substances
14. Have you ever attempted to

Change the behavior or behaviorsStop the behavior or behaviorsHide the behavior or bahaviorsLimit the behavior or behaviorsNone of the above
THE GERWE ASSESSMENT FOR BEHAVORIAL HEALTH
Please answer each question by placing an "X" in the appropriate box.
15. Has the feeling/behavior combination or combinations you have named ever created.

A problem in your lifeOccasional problems in your lifeMany problems in your lifeContiuous problem in your life
16. List below the physical symptoms that occur when the feeling/behavior combinations you have named happen to you. (For example shallow breathing, nausea, rapid heart beat, light neck and shoulders, headaches, etc).
DRUG ABUSE SCREENING TEST (DAST)
Please place an "X" in the appropriate box

1. Have you used drugs other than those required for medical reasons?
- Y
- N
2. Have you misused prescription drugs? Y

NYOther
3. Do you misuse more than one drug at a time? YN
4. Can you get through the week without using drugs (other than those required for medical reasons)? Yo

No
-8-5
5. Are you always able to stop using drugs when you want to? YN

6. Do you misuse drugs on a continuous basis? YN
7. Do you try to limit your drug uses to certain situations? Y
9. Do you ever feel bad about your drug misuse? YN

8. Have you had "blackouts" or "flashbacks" as a result of drug use? YoNo
9. Do you ever feel bad about your drug misuse? YN

11. Do your friends or relatives know or suspect you misuse drugs? YN10. Does your spouse (or parents) ever complain about your involvement with drugs? YN
9. Do you ever feel bad about your drug misuse? YN

12. Has drug misuse ever created problems between you and your spouse? YNo
No 13. Has any family member ever sought help for problems related to your drug use? Y
HAVE YOU EVER

14. Lost friends because of your use of drugs? YN
15. Neglected your family or missed work because of your use of drugs? Y
16. Been in trouble at work because of drug misuse? Y

N
17. Lost a job because of drug misuse? Y

N
No

18. Gotten into fights when under the influence of drugs? Y
Patient Name
Patient ID #
N
20. Been arrested for driving while under the influence of drugs? Y

No19. Been arrested because of unusual behavior while under the influence of drugs?
21. Engaged in illegal activities to obtain drugs? Y

Y N22. Been arrested for possession of illegal drugs?
23. Experienced withdrawal symptomes as a result of heavy drug intake? Y

Ni
23. Experienced withdrawal symptomes as a result of heavy drug intake? Y

25. Gone to anyone for help for a drug problem? Y
23. Experienced withdrawal symptomes as a result of heavy drug intake? Y

26. Been in the hospital for medical problems related to your drug use? YN
23. Experienced withdrawal symptomes as a result of heavy drug intake? Y

28. Been treated as an outpatient for problems related to drug dependence or misuse? YN
25. Gone to anyone for help for a drug problem? Y

NNo 24. Had medical problems resulting from your drug use (memory loss, hepatitis, convulsions, or bleeding)? Y
26. Been in the hospital for medical problems related to your drug use? YN

No27. Been involved in a treatment program specifically relataed to drug use? Y
Scoring: Each positive response yields 1 point, except for questions 4, 5, and 7 which yield 1 point for a negative response

A score greater than 5 requires further evaluatin for substance misuse problems.

Skinner H.A. The Drug Abuse Screening Test, Addictive Behaivior 7(4): 363-371, 1982
Patient Name
Check

MaleFemale
Females complete as appropriate

To the best of my knowldege I am pregnant.
To the best of my knowldege I am pregnant.

To the best of my knowledge I am not pregnant.
Female Only: If I even think I am pregnant or might be pregnant or might become pregnant I will notify the staff of
Initials
Name of Practitioner Explaining Consent_Dr Latonya Lee Niang edD LCADC Clinical Director
I hereby authorize and give my voluntary consent to the above name Medical DirecotrDiana Berger, MD and/or any

appropriately authorized assistants that he may select to administer or prescribe the drug Buprenorphine or Suboxone, as an element in the treatment for my dependence on narcotics (opiates-based) ddugs.,

The procedures necessary to assess and/or treat my condition have been explained to me and I understand it will involve my taking daily doses of Buprenorphine or Suboxone, or other drugs, which will help me control my dependence on Heroin and/or other narcotic drugs.
It has been explained to me Buprenorphine or Suboxone is also a narcotic (opiate-based) drug, which can be harmful if taken without medical supervision. I further understand Buprenorphine or Suboxone is an opiate based (partial agonist) classified as an addictive medication and may, like other drugs used in medical practice, produce adverse results. The alternative methods of treatment, the possible risk involved, and the possibilities of complications have been explained to me, but I still desire to receive Buprenorphine or Suboxone due to the risk of my return to the use of opiates and /or opiods such as Heroin, Oxycontin, Morphine, or other such drugs of the narcotic (opiate) family.

The goal of Buprenorphine or Suboxone treatment is total rehabilitation of the patient. Eventual tapering and withdrawal from the use of all drugs, including Buprenorphine or Suboxone, is an appropriate trreatment goal. I realize for some patients Buprenorphine or Suboxone treatment may continue for relatively long periods of time but the periodic consideration shall be given concerning my prospects for tapering and complete withdrawal from Buprenorphine or

Iunderstand I may withdraw from the treatment program and discontinue the use of the drug at any time and I shall be

afforded tapering and cessation under medical supervision.

I agree that I shall inform any doctor who may treat me for any medical problem I am enrolled in a narcotic treatment program, since the use of other drugs in conjuction with Buprenorphine or Suboxone may cause me harm.

Ialso understand during the course of treatment, certain conditions may make it necessary to use additional or different

procedures than those explained to me. I understand these alternate procedures shall be used when the Program Medical Director's judgement is considered advisable.

I certify that no guarantee or assurance has been made as to the results that may be obtained from Buprenorphine or Suboxone treatment. With full knowledge of the potential benefits and possible risks involved. I consent to Buprenorphine or Suboxone treatment, since I realize I would otherwise continue to be dependent upon and abuse narcotic drugs.
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INITIAL PATIENT SCREENING

THE GERWE ASSESSMENT FOR BEHAVORIAL HEALTH

THE GERWE ASSESSMENT FOR BEHAVORIAL HEALTH

DRUG ABUSE SCREENING TEST (DAST)