Care365 Addiction Treatment Centre

First Name and Last Name*

First NameLast Name
Health Card Number*
Version Code*
Birth Date*

MonthDayYear
Phone Number*
Format: 0000000000.
Gender*

MaleFemalePrefer Not to Say
Are you pregnant?*

YesNo
Address*

Street Address

CityProvince

Postal Code
Emergency Contact*

First NameLast Name
Emergency Phone Number*
1. Current Legal Status:*

No problemsOn probation/paroleAwaiting trial/sentencing
2. Relationship Status:*

Married/partnered/C/LSingleSeparated/divorced
3. Employment Status::*

Full/Part time workingUnemployedDisabledRetiredStudent
4. Income Source:*

EmploymentOntario WorksODSPOther
Do you have any children*

YesNo
Who is in custody of your children?*
Who lives in your household?*
Are You currently on any addiction or pain management programs?*

YesNo
Which addiction/ pain treatment program are you in?*

MethadoneSuboxoneKadianDilaudid (Hydromorphone)OxycodonePercocetSomething else
What is you current dose?*
When was your last dose?*

MonthDayYear
Date
From which pharmacy you received your last dose?*
Were you ever in any addiction treatment program before?*

YesNo
When was the last time you were in addiction program*
Which addiction/ pain treatment program were you in?*

MethadoneSuboxoneKadianDilaudid (Hydromorphone)OxycodonePercocetSomething else
Did you achieve the result you expected?*

YesNo

What is you current drug of choice?

Rows	Amount Used	Since when?	First Use	Last Use
Cocaine
Crystal Meth/ Cocaine
Benzodiazepines (Ativan, Valium, Xanax)
Heroin
Percocet, Oxy, Perks
Dilaudid
Fentanyl
Barbiturates (Fiorinal)
Other Substances
Alcohol

Have you ever used non-prescription and non-medical intravenous IV injection?*

Never injectedInjected within last 12 monthsinjected over 1 year ago
Do you have any allergies?*

YesNo
What are your allergies?*
Are you currently using any prescribed medications including narcotics like Tylenol 3 or Percocets?*

YesNo
Provide the list of medications that you are currently using and why they were prescribed?*
PAST MEDICAL HISTORY

Have you been tested for any of the following?

Would you like to be tested for any of above?*

YESNO
Please check all that apply, as honestly as possible, so we can support you based on your needs.

I have taken more opioids or used them for longer than I planned.I have wanted to cut down or stop using opioids but found it hard or unsuccessful.I spend a great deal of time obtaining opioids, using opioids, or recovering from their effects.I get cravings or have a strong desire to use opioids.My opioid use has resulted in failure to fulfill major obligations at work, school, or home.I have continued using opioids even though they caused problems with family, friends, or others.I have given up or reduced important social, occupational, or recreational activities because of my opioid use.I have used opioids in situations that were physically hazardous.I have kept using opioids even though I knew they were causing or worsening a health or mental issue.I have needed more opioids to get the same effect, or I have noticed they don’t work like they used to.I have had withdrawal symptoms like feeling sick, anxious, shaky, having muscle pain, sweating, or trouble sleeping when stopping opioids, or I have taken more to avoid feeling sick.Other
Would you like us to know anything before we contact you so we can help you better?
For Office Use Only (Don't Fill)

Simply submit the form
Treating Doctor/NP
CPSO/CNO#
Doctor's Phone#
Doctor's Fax#
Should be Empty:

PAST MEDICAL HISTORY