Suboxone Follow-up Visit Form

Please insert the appropriate number:

	Days	Weeks	Months	Years
I have taken Buprenorphine for:
Prior to Buprenorphine treatment, I have been addicted to pain pills for:

Please indicate Yes or No to the following questions:

	Yes	No
I have been taking Buprenorphine exactly as prescribed
Since my last appointment, I have abused pain pills
Since my last appointment, I have used substances of abuse (marijuana, alcohol, Xanax, Klonopin, Valium, Cocaine, Methamphetamine, LSD, others not listed, etc..)
I have been advised of the potential health risk, such as respiratory distress involving the use or combination of alcohol, benzodiazepines, and Suboxone/Subutex/Buprenorphine
I am taking, have taken, or been prescribed pain medications, by another doctor, since my last appointment here.
I have had triggers and cravings since my last appointment
I have had new stressors? (ex broken relationships, loss of employment, loss of family)

My dose of Buprenorphine needs to be

IncreasedDecreasedStay the Same
My recovery program includes (Select all that apply):

Groups at this office/Reading Thought of the Day on the Website12 Step Meetings (AA/NA)Talking with a Sponsor/People in recoveryPrayer/MeditationSeeing an Individual CounselorRecovery LiteratureExerciseHobbiesOther
I have a history of (Select all that apply):

Liver DiseaseHIVSTD of any formHepatitis of any form
Did you bring medication wrappers, bottles or prescription container?*

YesNoNot applicable due to Virtual Visit
If no, explain
Name

First NameLast Initial
Today's Date

MonthDayYear
Date
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