New Suboxone Patient Intake (Please complete all information)
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1 ALLAN L. LEVY, MD, PC 172 THOMAS JOHNSON DRIVE SUITE 204 FREDERICK, MD TELEPHONE: FAX: New Suboxone Patient Intake (Please complete all information) Name: Initial Appointment Date: PERSONAL Date of Birth: / / What town do you live in? How long have you lived there? Where did you grow up? Who do you live with? qself qparents qchildren qspouse qother SCHOOL qhigh School qassociate qbachelors qmasters/phd qother Where did you last go to school? What did you/are you studying? (If applicable) MARITAL STATUS (check closest answer): qsingle qmarried qdivorced/separated qwidowed qlive with significant other qother (not listed) Children(s): First Name: Age: WORK HISTORY If currently working: Employer qfull time qpart time qtotal hours per week If not working Last time employed: Type of work: MEDICAL HISTORY Primary Care Doctor When was your last physical Other important doctors: Important Medical conditions: Drug allergies: Current Medications (not including psychiatric meds):
2 Last psychiatrist Name (if applicable): What was the reason you left your last psychiatrist? When (if ever) you were first treated for a psychiatric problem: What was the problem? What diagnoses have you been given (list the ones that you think describes your problem If you have had psychiatric hospitalizations: When was the first hospitalization: How many times have you been hospitalized? What were the reasons you were hospitalized? Have you ever left a hospital against medical advice? qyes qno If yes explain: PSYCHIATRIC MEDICATION HISTORY: Medication Side effects Effectiveness Reason stopped* Do you have thoughts that you would rather be dead? (Put X? on line) None rarely often most of the time If you have recently thought of killing yourself, how have you thought of doing it? 1. 2.
3 Have you ever tried to kill yourself? qyes qno If yes when and how? LEGAL Current legal concerns: Past legal concerns: PAST CONCERNS Appetite: Very poor Good Too much Weight gain or loss in the past 3 months pounds Do you have trouble sleeping too much or too little? Please describe: CURRENT CONCERNS What is the biggest reason you are seeking help? What are other important concerns? What are the biggest stressors in your life (biggest first)? How much support do you have from family (1-10): Who (Mother, spouse, etc)? How much other support do you have (1-10)? Who (friends, minister, etc): How well are you functioning at home and socially? Very poor Fairly Very well
4 Major problem at home & socially: How well are you functioning at work or school? Very poor Fairly Very well Major problem at work or school: What are your goals for treatment (please be as specific as possible)? Medical and Substance History qasthma/respiratory qcardiovascular (Heart, qgi (stomach, bowels) qhead Trauma cholesterol, chest, qdiabetes blood vessels) qliver problems qthyroid qepilepsy (seizures) qsexually transmitted disease qnutrition qhiv/aids qhigh blood pressure qanemia (low blood count) qpancreas qabnormal pap smear Other: Are you pregnant? qyes qno Allergies (medicine, bees, peanuts etc): Cigarettes Now: qyes qno How many a day: In past: qyes qno How many a day? When did you quit? Have you been treated for substance use: qyes qno: Please describe where, when, and for how long: What did you like best about your treatment? What did you like least about your treatment? Substance Use History: Alcohol Caffeine Cocaine and crystal meth Inhalants (aerosols) LSD/Hallucinogens Marijuana/pot PCP Stimulants/amphetamines Benzos (sleeping pills/ant-anxiety) Ecstasy No In past Route (IV, by mouth) Describe how you used it
5 Do not write below this line Dependence criteria Tolerance: Cost of getting/recovering: Withdrawl: Social/occup cost: Greater use than intended: Use despite consequences: Can t quit: Last used? First experience: Last experience: How much last week: Why use?: Sexual encounter on drugs: Last Sobriety: REMS 1. DSM opioid dependence 2. Risks Page Storage 4. Induction in office 5. Limited amounts 1 st Visit 6. 2 nd Visit < 2 Weeks
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Dr. Marc E. Lewis Dr. Meenakshi Aggarwal Anne Dunne, FNP Melinda Sanfilippo, FNP
Thank you for attending your annual health maintenance exam. Depending on your health insurance plan, you may receive preventative benefits for a reduced copay or no copay. We would like to clarify the
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
New Client Information. address: Date of Birth:
Milwaukee Area Psychological Services, S.C. (MAPS) 401 E. Kilbourn Avenue, Suite 402 Milwaukee, WI 52302 414-269-8660 (phone) 414-269-8656 (fax) New Client Information Your responses to the following questions
Addiction History. Patient Assessment. Objectives. Cost. Initial Screen. Patient Assessment 25/04/2017. Substances. Age Started
Addiction History Patient Assessment Methadone and Suboxone 2017 Dr. Morris Markentin, 2017 Substances Current substance use and amount Age Started Each substance Route of use each substance Inhalation