Home Address: City: State: Zip Code: Referral Source (Therapist, Treatment Program, Etc...): Name: Age: Gender: Name: Age: Gender: Name: Age: Gender:

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Transcription:

Naltrexone Pellet Insertion Intake Form Name: Date of Birth: / / Contact Information: Phone: E-Mail: Home Address: City: State: Zip Code: Referral Source (Therapist, Treatment Program, Etc...): Why are you seeking Treatment? Are you married, partnered or single? Do you have children? Y N How many? Name: Age: Gender: Name: Age: Gender: Name: Age: Gender: Is your family willing to support you and/or participate in the treatment procedure? Treatment History (Please describe any treatment you ve received from Residential Treatment Programs, Outpatient Programs, Clinicians and/or Therapists and include reason for discharge):

History of Substance Abuse: (Include Date of last use) DOC: How Much/Quantity/Dosage: How Often: Opiates: How Much/Quantity: How Often: Alcohol: How Much/Quantity: How Often: Benzodiazapines: How Much/Quantity: How Often: Cocaine: How Much/Quantity: How Often: Meth: How Much/Quantity: How Often: Bath Salts: MDMA: Marijuana: Other: How Much/Quantity: How Often: How Much/Quantity: How Often: How much/quantity: How Often: How Much/Quantity: How Often: Are you currently acting out in any other forms of (Process) addictions? (ex: sex, internet, gambling, gaming, over-spending, shopping, shoplifting,overeating,compulsive eating or anorexic behaviors, etc...) Have you ever been diagnosed or treated for any of the following? Anxiety: Depression: ADD/ADHD: Anorexia: Bi-PolarDisorder: Borderline Personality Disorder: Bulimia: Compulsive Overeating: Dissociative Identity Disorder: Schizophrenia: Aspbergers: Cutting: OCD: Other: Have you attempted Suicide or Overdosed in the last year (if yes, date of last attempt)? Y/N If yes, please explain the last attempt, method attempted, treatment/hospitalization?

Are you currently on probation or parole or have any pending court dates? Y / N Name of Probation/Parole Officer, Attorney or CPS Case Manager? Phone: E-mail: Studies have indicated the single best predictor of long term sobriety is participation in an intensive outpatient, individual counseling or a twelve step program. Are you willing to attend outside 12-Step or Smart Recovery Meetings? Y N Are you currently working one on one with an addiction counselor? Y N Please List ALL Medications: _ Prescription: Do you have a current or past diagnosis of any of the following: Diabetes type I / type II High blood pressure Cancer Heart disease Hepatitis / type HIV Lyme disease Chronic fatigue Fibromyalgia Any other chronic and/or infectious diseases or life event that you never fully recovered from? Emergency care of other hospitalization? Please list any history of emergency care, such as stroke, heart attack, acute gallbladder, or pancreas, kidney stone, ectopic pregnancy, broken bones, vehicular accident, concussion, or other injury or severe acute illness that resulted in hospitalization.

Review of Systems Please circle any current problem; please mark a P next to any past problem Head and Face Headache Ringing in the ears Neck swelling lumps Dizziness Earaches Sore throat Loss of balance Difficulty hearing Dental problems Blurry vision Loss of smell Sore/bleeding gums Fainting/blackouts Nose bleeds Difficulty swallowing Red eye / eye pain Hoarse voice Cold sore Cataracts / glaucoma Grinding teeth Impaired speech Chest Wheezing Chest cold Unexplained fever Coughing up blood Palpitations Rapid/skipped beats Coughing up phlegm Chest pain High blood pressure Shortness of breath Night sweats Swollen feet or ankles Abdomen Stomach pain Diarrhea Loss of appetite Indigestion Constipation Excessive appetite Nausea Yellow/jaundice Blood in stool Vomiting Gas/bloating Light colored stool Blood in vomit Rectal pain Rectal itching Genitourinary Frequent urination Blood in urine Recurrent bladder infection Urge to urinate Kidney stones Genital sores Incontinence Sexual difficulty Sexually transmitted disease Vaginal yeast infection Pain with urination Genital discharge Musculoskeletal Aching muscles Bones break easily Sore joints Numbness/tingling Weakness Leg cramps Restless leg Swollen joints Tender points Skin Acne Rashes Easy bruising Itching Lesions Hives Athletes feet Eczema Dry Endocrine Always cold Always tired Loss /thinning hair Brittle nails Difficulty with weight Low body temperature Always hot Weakness Increased thirst

Mental/Emotional Anxiety Foggy thinking Memory loss Loss of sensation Lack of concentration ADD / ADHD Depressed mood Restlessness Suicidal thoughts Excessive worry Mood swings Angered easily Loneliness Suspicious/jealous Shy/timid Scary dreams Female Lumps in breast Pelvic pain Pain with intercourse Breast pain Vaginal itching/burning Missed periods Heavy periods Spotting between periods Hot flashes Genital eruptions Symptoms prior to menses Dry or thin vaginal wall PCOS Ovarian or uterine problems Age of first menses : period occurs every days regular? y /n Period usually lasts days First day of last period : # pregnancies # of births # or miscarriages Has menopause occurred yet? If yes, how long ago? Date of last Pap? Date of last abnormal Pap? I certify that the above information is complete and I have not knowingly omitted any significant condition(s) that may be potentially life threatening. Signed Date:

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