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Screening Form

Appointment Request

DETOX PROGRAMS SCREENING FORM

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Requestor Information
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Current PCP or Specialist Name:
Phone:
Current Counselor/Psychiatrist Name:
Phone:
Aftercare Treatment Plan:
Pharmacy Phone:
 
Current Daily Opiate Use:
Amount Used Daily:
Means of Use:
First Opiate Use:
Age When Started:
Previous Substance Abuse:
Previous Drug Treatment:
(when and how long was abstinence?)
Legal Problems:
Previous Methadone Use:
If Yes, how much:
Other Drug Use in the Past and Currently:
Past Alcohol Usage:
Past Cocaine Usage:
Past Usage of Other Substances:
Present Alcohol Usage:
Present Cocaine Usage:
Present Usage of Other Substances:
Overdoses<(how many):
Suicide Attempts<(how many):
 
Past Medical History:
Current Medications:
Allergies to Medications:
Family History:
Mother (age):
Father (age):
Siblings (age):
Family Hx S/A:
MA side:
PA side:
Family Medical History:
Mother: (please list any medical conditions or problems)
Father: (please list any medical conditions or problems)
 
Social History:
Married:
Children:
Lives with:
Smoke: (Packs per day)
Pregnant:  LMP:
 
Employment:
Job Title:
Job Description:
Additional Notes Pertaining to Detox:

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