Altmed Medical Center
8551 Rixlew Lane Suite #140 A, Manassas, VA, 20109 | 11885 Holly Lane Suite 4, Woldorf, MD 20601 | 9816 Winchester Rd, Front Royal, VA 22630 | 7700 Little River Turnpike Suite 104 Annandale, VA 22003 Ph: (703) 361-4357 | Website: www.altmedfirst.com | Email: info@altmedfirst.com
Patient Name
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Date
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Day
Year
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Date of Birth
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Tick the answer that best fits the way you feel now
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(0)
(1)
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I feel anxious
I feel like yawning
I am perspiring
My nose is running and/or my eyes are watery
I have goose bumps and/or chi ls
I feel nauseated or like I may need to vomit
I have stomach cramps and/or diarrhea
My muscles twitch
I feel dehydrated and/or have not had much appetite
I am having difficulty sleeping
I have a headache
My muscles and bones ache
I feel like using right now
I would rate my overall level of withdrawal as
Do you feel you need a dosage change?
No
Yes
If yes, select below to adjust the dosage
Up
Down
Have you used alcohol or other drugs since your last visit?
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Yes
No
If "yes," please describe what, when, and how much.
Please describe any life changes, triggers, or stressors that have occurred since your last visit.
Since your last visit have you relapsed?
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No
Yes
(if yes, please specify which substance and when)
Have you attended any AA/NA meetings since your last visit?
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Yes
No
Dates and Location
Have you established a support network? (family, non-drug using friends, spouse, significant other, etc.)
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Yes
No
Who?
Medication Change
Any Medication Change?
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Yes
No
List all Changes
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Name
Dose
Frequency(Per Day)
Prescribing Doctor
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2
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Side Effects/Symptoms (please circle all that apply):
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Fever
Fluttering of the heart
Constipation
Sedation (sleepiness)
Abdominal pain
Nausea
Chills
Double/Blurred vision
Dizziness
Sweats.
Explain other symptoms that you experienced which are not mentioned above, since your last visit:
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