New Patient Pre-Eval Form
Demographics
Name
First Name
Middle Initial
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
Phone Number
Email
example@example.com
Primary Insurance
If available
Member ID
If available
Address
Street Address
City
State
Zip Code
How long have you lived at current location?
Height
Input Height
Weight
Input Weight
Martial Status
Single
Married
Divorced
Widowed
Separated
Other
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Substance Abuse History
Substance Abuse History
Age of Onset
Method of Use
How often
Date of last use
Avg. 24 hour use amount
Alcohol
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Cocaine
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Marijuana
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Heroin
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Other Opiates
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Hallucinogens
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Methamphetamines / Amphetamines
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Stimulants
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Benzodiazepines
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
Inhalants
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
K2 / Synthetic Cannabis
Intranasal
Oral
Smoking
Inhalation
Injection
None
Other
Not in Past Month
1-3 Times/Month
1-2 Times/Week
3-6 Times/Week
Daily
Unknown
None
History of Overdose?
Yes
No
Approximate Date of last overdose:
How many times have you had a drug overdose?
Previous Drug and Alcohol and/or Mental Health Treatment
Have you been involved in previous treatment for D&A or Mental Health services?
Yes
No
Previous D&A and/or MH services.
Dates
Location/Type of Service
D&A Outpatient
D&A Inpatient
MH Outpatient
Have you ever attended AA/NA or Self-Help Group Meetings?
Yes
No
Do you currently attend AA/NA or Self-Help Groups?
Yes
No
Do you have a sponsor or a homegroup
Sponsor
Homegroup
Frequency of self-help program attendance in the past 30 days
Please Select
01-03 Times in Past Month
04-07 Times in Past Month
08-15 Times in Past Month
16-30 Times in Past Month
More than 30 Times in Past Month
No Attendance in Past Month
Same Attendance in Past Month Freqeucny Unknown
Do you gamble or have a history of gambling?
Yes
No
Please check any of the following that apply:
I've felt the need to bet more and more money
I've lied to people important to me about how much I gamble
I've felt the need to cut down and control my gambling
I've felt angry or annoyed when someone commented on my gambling
I've felt bad/guilty about my gambling
I've gambled first rather than take care of important areas of my life
None/NA
Tobacco / Smoking
Do you smoke or use tobacco?
Yes
No
For how many years have you used tobacco products?
Type of Tobacco Use
Light Cigarette Smoker (1-9 per day)
Moderate Cigarette Smoker (10-19 per day)
Heavy Cigarette Smoker (20-39 per day)
Very Heavy Cigarette Smoker (40+ per day)
Chewing Tobacco / Smokeless Tobacco
Nicotine Pouches
Vape/E-Cigarette
Other
On a Scale of 1 to 10, How Ready Are You to Quit Tobacco?
Not Ready At All
1
2
3
4
5
6
7
8
9
Very Ready
10
1 is Not Ready At All, 10 is Very Ready
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Health History
Family Health History
Family Member(s)
Comments
Cancer
Diabetes
Heart Disease
Hypertension
Stroke
Seizure
High Cholesterol
Addition
Psychiatric
Health Problems
Not Satisfied
Past
Never
Any thoughts?
Anemia
Arthritis
Bleeding Disorder
Blood Pressure
Bone/Joint Problem
Cancer
Diabetes
Epilepsy/Seizures
Eye Disease
Glaucoma
Fibromyalgia
Muscle
Headaches
Head Injury
Brain Tumor
Hearing Problems
Heart Disease
Hepatitis
Kidney Disease
Lung Disease
Menstrual Pain
Oral/Dental Health
Stomach Issues
Stroke
Thyroid
Tuberculosis
AIDS/HIV
STI/STD
Learning Problems
Speech Problems
Anxiety
Bipolar
Depression
Eating Disorder
Hyperactivity/ADD
Schizophrenia
Sexual Problems
Sleep Disorder
Suicide Attempts
Suicide Thoughts
Medications
Medication
Dosage/Strength
Frequency
Med 1
Med 2
Med 3
Med 4
Med 5
Med 6
Med 7
Med 8
Additional Medications
Any known allergies?
Yes
No
Please specify allergies:
Past Surgical Procedures/Serious Injuries
Operation / Hospitalization
Year
Comments
1
2
3
4
Additional
Primary Care Physician
PCP Name
Organization
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Pharmacy
Please enter your preferred pharmacy information below
Pharmacy Name
Address
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact
Emergency Contact Name
First Name
Last Name
Relationship:
Phone Number
Please enter a valid phone number.
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PHQ-9, Trauma History Questionnaire
PHQ-9: Over the past 2 weeks, how often have you been bothered by any of the following problems?
0. Not at all
1. Several Days
2. More than half the days
3. Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat Difficult
Very Difficult
Extremely Difficult
Trauma History Questionnaire
The Following is a series of questions about serious or traumatic life events. Knowing about the occurrence of such events, and reactions to them will help us to develop programs for prevention, education, and other services. For each event, indicate whether it happened &, if it did, the number of times & your approximate age when it happened.
General Trauma History
Yes
No
Number of times
Approximate Age
Comments
Has anyone ever tried to take something directly from you by using force or the threat of force, such as a stick-up or mugging?
Has anyone ever attempted to or succeeded in breaking into your home.
Have you ever been in any situation in which you were serious injured? (is yes, specify)
Have you ever been in any other situation in which you feared you might be killed or seriously injured? (If yes, specify)
Have you ever seen someone seriously injured or killed? (If yes, specify)
Have you ever had a serious or life-threatening illness? (If yes, specify)
Have you ever received news of a serious injury, life-threatening illness, or unexpected death of someone close to you? (If yes, specify)
Has anyone ever pressured or forced you into unwanted physical or sexual contact?
Has anyone, including family or friends, ever attacked you with a gun, knife, or other weapon?
Have you ever experienced, witnessed or been exposed to domestic violence?
Have you experienced any other extraordinarily stressful situation or traumatic event that is not covered above? (If yes, specify)
Stages of Change Readiness and Treatment Eagerness Scale
SOCRATES is an experimental instrument designed to assess readiness for change in individuals with substance use disorders. The instrument yields three factorially-derived scale scores: Recognition (Re), Ambivalence (Am), and Taking Steps (Ts).
SOCRATES
Strongly Disagree
Disagree
Uncertain
Agree
Strongly Agree
1. I really want to make changes in my use of substances.
2. Sometimes I wonder if I am an addict or alcoholic.
3. If I don’t change my drug/alcohol use soon, my problems are going to get worse.
4. I have already started making some changes in my use of drugs or alcohol.
5. I was using drugs or alcohol too much at one time, but I’ve managed to change that.
6. My substance use is causing problems with the law.
7. I have a problem with substances.
8. I’m not just thinking about changing my drug or alcohol use, I’m already doing something about it.
9. I have already changed my drug or alcohol use, and I am looking for ways to keep from slipping back to my old pattern.
10. I have serious problems with drugs and/or alcohol.
11. Sometimes I wonder if I am in control of my drug or alcohol use.
12. My drug or alcohol use is causing a lot of harm.
13. I am actively doing things now to cut down or stop my use of substances.
14. I want help to keep from going back to the drug or alcohol problems that I had before.
15. I know that I have a drug or alcohol problem.
16. There are times when I wonder if I use drugs or alcohol too much.
17. I am an addict or alcoholic.
18. I am working hard to change my substance use.
19. I have made some changes in my substance use, and I want some help to keep from going back to the way I used before.
Recognition
Ambivalence
Taking Steps
Decile Scores
Recognition
Ambivalence
Taking Steps
90 Very High
19–20
39–40
80
18
37–38
70 High
35
17
36
60
34
16
34–35
50 Medium
32–33
15
33
40
31
14
31–32
30 Low
29–30
12–13
30
20
27–28
9–11
26–29
10 Very Low
7–26
4–8
8–25
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TB/HVC/HIV Rick Assessment
HCV Screening Questions
Were you born between the years of 1945 & 1965
Yes
No
Do you currently use IV drugs?
Yes
No
Have you previously used IV drugs?
Yes
No
Have you received a clotting factor produced before 1987?
Yes
No
Have you been on hemodialysis?
Yes
No
Human Immunodeficiency Virus Screening Questions
Do you currently use IV drugs?
Yes
No
Have you previously used IV drugs?
Yes
No
Do you engage in unprotected sexual activities?
Yes
No
Do you engage in sharing needles?
Yes
No
Tuberculosis Screening Tool
Have you traveled extensively (more than 4 weeks) outside the U.S in the last five years to high TB-incidence areas (Asia, Africa, South America, Central America)?
Yes
No
Are you an immigrant from a high TB-risk foreign country (includes countries in Asia, Africa, South America, and Central America)?
Yes
No
Have you resided in any of these facilities in the past year: jails, prisons, shelters, nursing homes and other long-term care facilities such as rehabilitation centers? (If an individual was a resident of any of these facilities and tested with the past three months, they do not need to be reassessed).
Yes
No
Have you had any close contact with someone diagnosed with TB?
Yes
No
Have you been homeless within the past year?
Yes
No
Have you ever injected drugs?
Yes
No
Do you or anyone in your household currently have the following symptoms, such as a sustained cough for two or more weeks, coughing up blood, fever/chills, loss of appetite, unexplained weight loss, fatigue, night sweats?
Yes
No
Do you currently have or anticipate having any condition that would decrease your immune system? (Examples: HIV infection, organ transplant recipient, treatment with TNF-alpha antagonist (e.g. infliximab, etanercept, others), steroids (equivalent dose of Prednisone 15mg/day for one month or longer) or any other immunosuppressive medications)
Yes
No
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Personal and Social History
Employment
Are you currently Employed
Yes
No
Employment Status:
Full-Time
Part-Time
Seasonal
Student
Unemployed
Laid Off
Retired
Disabled
Student
Other
Current Employer
Position
Duration of employment
Legal
Current Legal Status:
Yes
No
Legal Status (Check all that apply)
Charges Pending
Incarcerated
Parole
Probation
Drug Court
DUI Court
JRS
Mental Health Court
Other
Do you have history of legal charges?
Yes
No
If yes, specify
Children/Family
Do you have children?
Yes
No
How many?
Military
Have you ever served in the military?
Yes
No
Specify Branch:
Rank:
Type of Discharge:
Please Select
Bad Conduct
Dishonorable
Entry Level Separation
General
Honorable
Office
Other
Education
Highest Level/Grade Completed
Please Select
None
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
High School Diploma
GED
Some College
Associates Degree
Bachelors Degree
Graduate Degree
Technical Institute/Trade School
Where did you attend High School?
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Certified Recovery Services Referral
Certified Recovery Services will provide support before, during and after treatment through lived experience of the recovery process. CRS services include: Guidance in the recovery process, referral for needed support services, referral for self-help recovery supports, moral support, coaching and advocacy throughout the recovery process, guidance in building healthy social relationships and leisure, recreational activities.
Are you interested in accessing Recovery Support Services?
Yes
No
Select areas where you desire additional support:
Health Care Coverage (MA, Market Place)
Basic Needs (Food, clothing, shelter, transportation)
Physical Health (Medication mgmt., PCP, Dental)
Emotional/Mental Health (Psychiatry & Mental Health Referral)
Family (counseling, education, resources)
Child Care
Legal Status (referral for legal assistance)
Life Skills (cooking, cleaning, bills, shopping)
Social (develop healthy leisure activities)
Employment (job seearch, resume writing, etc.)
Recovery Coaching / Support Group Access
Treatment Referrals (access to detox/inpatient)
Peer to Peer Support
Other
Do you have any other priorities at this time that you feel would be helpful to focus on?
Submit
Should be Empty: