SUBSTANCE USE QUESTIONNAIRE

VITAL TOTAL HEALTH Medical Group, Inc.

Walnut Creek - San Francisco - Oakland - Pleasanton - Folsom - Beverly Hills

www.VitalTotalHealth.com www. VitalOncall.com

Central Phone and Fax (925) 388-9800

Name *

Today's Date:

Date of Birth *

Date

Age *

What is your dominant hand? *

Right Hand Left Hand

What is your Height? *

What is your Weight? *

CHIEF COMPLAINTS *

Interested in (check all that applies) *

Detox Medication-assisted Treatment with Buprenorphine Pain Treatment Psychology / Counseling Services 30/60/90-day Drug Rehab Extended Programs ADHD Treatment PTSD Treatment

SUBSTANCES USED *

	No	Yes	Date Start	Date Last Used	Ever OD?	Amount per Day
Marijuana
Alcohol
Barbituates Ambien
Valium Ativan Xanax
MDMA (Ecstasy, Molly)
Amphetamines
Cocaine
LSD Mushrooms
Mescaline
Meth
PCP (Angel Dust)
Codeine
Hydrocodone (Norco, Vicodn)
Morphine
Oxycodone
Hydromorphone
Heroin
Fentanyl
Other

DAILY ACTIVITIES: *

	Yes	No
Can you Wash, Bathe, and Dress without assistance?
Can you sit through a movie?
Can you walk without assistance for over 30 minutes?
Can you get off the floor without your hands?
Can you lift a heavy bag of groceries without problems?
Can you carry a 10 pound bag 50 feet?
Can you do all your recreational activities and work?
Does your problem affect relationshps with family and friends?

PRIOR TREATING DOCTORS or PROVIDERS:

	Name
Physician
Clinic
Residential
Outpatient
Hospital

PRIOR TREATMENT FOR PRESENTING PROBLEM: Have you had? *

	No	Yes	Dates	Did it help?
Alcohol Anonymous, AA
Narcotics Anonymous, NA
Acupuncture
Psychology Counseling Services
Psychiatric Services
Detox Inpatient
Detox Outpatient
Detox Residential
Court-ordered Treatment
Group Therapy
Methadone Clinic
Medication-assisted Therapy
Buprenorphine (Subutex, Suboxone)
Naltrexone
Disulfiram (Antabuse)

PAST INJURIES: Have you had any past injuries? If so, then note below. *

Yes No

PAST INJURIES:

	Date	Description of Injury
Injury #1
Injury #2
Injury #3

Do you have any Pain? *

No Yes

Date of Injury or Illness:

Date

Area(s) of Body affected:

Diagnosed as:

Frequency of Pain:

Constant, greater than 90% of time Frequent, 75% of time Intermittent, 50% of time Occasional, 25% of time Gone now, but had pain in the past.

Pain Scale intensity (0 to 10)

10 - Severe, unable to move 7-9, Moderately severe, prevents you from standing and walking after ten minutes 4-6, Moderate, limits prolonged (30 min) activities such as sitting, standing, walking 1-3 Slight, able to do activities, but the pain is made worse

PAST MEDICAL HISTORY: *

	Yes	No
Seizures
Stroke
Glaucoma
Thyroid Disease
Diabetes
Hypertension
High Cholesterol
Heart Disease or Irregulr rhythm
COPD or Emphysema
Asthma
GERD or Reflex Gastritis
Pancreatitis
Hepatitis
Kidney problems
Prostate problems
Pelvic-Genital problems
Arthritis
Chronic Pain
Chronic Injection
Cancer
Addiction
Depression
Anxiety
ADHD

PAST SURGERIES: Have you had any surgeries? *

Yes No

List of Any Past Surgeries:

	Month/Year	Operation performed	Did it help?
Operation #1
Operation #2
Operation #3
Operation #4

FAMILY HISTORY: Do any of your family members suffer from? *

	No	Yes	Mother	Father	Sibllings	Children
Thyroid Disease
Diabetes
High blood pressure
Heart Disease
Stroke
Arthritis
Autoimmune Disease
Cancer
Addiction
Depression, or other Psych

SOCIAL HISTORY: *

	Yes	No
Are you married or live with a partner?
Do you live with other people?
Do you have children?
Do you smoke cigarettes?
Do you drink alcohol daily?
Do you use any street drugs?

Any Problems or Disruption with? *

	No	Yes	Please describe the problems
Friends
Family
School
Work
Legal

ALLERGIES TO DRUGS OR ANESTHESIA? *

Yes No

List What Medicines or Drugs allergic to, and your reaction:

	Medication Name	Allergic Reaction (Rash, Swelling, Shortness of breath)
Drug #1
Drug #2
Drug #3

DO YOU TAKE ANY MEDICATIONS or SUPPLEMENTS? *

Yes No

PRESENT MEDICATIONS: Prescribed Medicines & Over-the-Counters

	Drug Name	Strength mg	How often?	For what conditiom	Prescriber
Drug #1
Drug #2
Drug #3
Drug #4
Drug #5
Drug #6
Drug #7
Drug #8

Have you tried any drugs in the past for your problem? *

Yes No

List any drugs used in the past for your problem:

	Medication Name	Strength mg	Did it help?	Why did you stop?
Drug #1
Drug #2
Drug #3

GENERAL HEALTH QUESTIONS: Do you have any problems with

	Yes	No
Fevers. Chills. Sweating.
Sleep less than 6 hours
Headaches. Migraines.
Difficulties with Vision
Difficulties with Hearing
Nasal or Sinus Congestion. Nose bleeds. Unable to smell or taste.
Problems with teeth or gum. Sore throat. Swollen glands.
Chest pain. Rapid or irregular heart beats. Feet swelling.
Shortness of breath
Wheezing. Coughing.
Nausea. Vomiting.
Heartburn. Abdominal pain.
Yellow jaundice
Diarrhea. Constipation.
Bright red blood in stool. Or dark black stool.
Poor libido
Pelvic pain
Sexual Dysfunction (ED in men. FSD in women)
Frequent urination. Burning. Urgency. Weak urine flow.
Wake up to urinate
Weakness. Fatigue.
Joint pain. Muscle pain.
Problems with Balance
Skin rashes. Acne. Goosebumps. Redness. Infection. Open wound. Track marks. Easy Bruising.
Hair Loss
Numbness. Tingling.
Seizures
Forgetfulness
Repeatedly or overly worried. Rapid thoughts.
Trouble falling asleep
Snoring
Feeling sad or depressed.
Feeling hopeless. Suicidal thoughts.
Hallucinations. Flashbacks. Delusions. Paranoia.
Weight Loss. Poor appetite.
Weight Gain. Excessive appetite.

Signed *

Clear

Date *

Date