Addiction Medical Clinic LLC

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1 Chief Complaint and Symptom: Substance Abused: Current amount per use and Frequency/day used: Last use: Date & Time: Route: Current and in the past: Duration of Use: Both Current and Lifetime: Have you ever been treated for substance misuse: Yes/ (Please describe below when, where and for how long) Have you ever experienced withdrawal symptoms in the past? Yes/ ( circle all that apply) Blackouts Tremors Nausea/vomiting Diarrhea Anxiety Sweats Body Aches/Cramps Runny nose Alcohol Seizures DTs 1

2 Substance Use History: Yes/Past Yes/w Route How much How often Date/time last use Quantlty last used Tobacco Alcohol Caffeine Heroin Pain killers Methadone Marijuana Meth Tranquilizers/s leeping pills Cocaine/Crack LSD or Hallucinogen PCP Stimulants Inhalants Ecstasy Did you stop any of the above due to dependence? Yes/: (Please List) What was your longest period of abstinence? Social/Family history: Marital Status: (Circle one) Married Long Term Relationship Single Divorced/Separated Years Married/LTR: Times Married: Times Divorced: Does spouse/partner use drugs? Yes 2

3 Children: Yes Current Ages: Are they Living with you? Yes/. If where are they Living? Where are you currently living? Do you have any Family nearby? Do you Have a PCP? Yes. Last Visit: Education: (Circle ) High School Grade College Professional/Vocational Graduate School Employment: Are you currently employed? Yes If where where you last employed? What type of work do/did you do? How long did/have you worked there? Legal issues: Have you ever been arrested or convicted? Yes/. Any legal issues we need to be aware of? Deferred Prosecution? Court Ordered treatment? Have you ever been abused? Yes 3

4 Have you ever been in counselling or therapy? Yes If Yes please give details: Have you ever attended: Yes/ (Circle) Alcohol A Cocaine A Narcotic A Overeaters A If you are not currently attending, what led you to stop? Any family history of Substance abuse? Behavioral History: Number sexual partners in past 5 yrs.: 0, 1, 2 5, >5 Opposite sex Same Number sexual partners in last 4 wks: 0, 1, 2 5, >5 Opposite sex Same Have you shared works? How recently? Contraceptive used: Condoms used: times/last week STD: Ever had Syphilis Gonorrhea Herpes Chlamydia Genital warts Medical History: Any Allergies? (Medication, Food etc) Any medical conditions? (Circle if positive) Asthma/COPD Cardiovascular Hypertension Diabetes Epilepsy/Seizure GI Disease Head Trauma HIV/AIDS Liver problems STD Thyroid condition MVA Abnormal Pap smear Nutritional deficiency Chronic Pain Back issues Family history of any medical conditions? Have you or family member diagnosed with psychiatric or mental Disease? Yes/, Please provide details 4

5 Any Major surgeries or Hospitalizations? Yes/, Please list below Are you currently taking any Medications or herbal medicines/otc meds Vitamins etc? Yes/ please list below and how much and often? Have you ever been prescribed with antidepressant? Yes/. If yes please provide details: Are you pregnant? Yes Trying to get pregnant? Yes LMP: Last Pap Smear: Review of Systems: (Circle if Positive) Drug/withdrawal related: Runny nose, Bodyaches, Irritable, Chills, Nausea, Stomach cramps, Diarrhea, Agitation, Difficulty concentrating, Tremors. General: Weight change, Loss of appetite, Fever, Night sweats, Fatigue. Immunol./Integ.: Swollen glands, Skin rash, Abscess. ENT: Poor vision, Poor hearing, Dental problems, Hoarseness. Pulmonary: Cough, Wheezing, Shortness of breath. Circulatory: Chest pain, Fainting, Palpitations, Ankle swelling, Cold or painful extremity. Gastrointest.: Heartburn, Abdominal pain, N / V / D / C (circle), Hemorrhoids. Urogenital: cturia, Urgency/freq., Hematuria, Discharge, Decreased Libido, Irregular Periods, Amennorhea. Musculoskeletal: Back pain, Joint pain, Joint swelling, Muscle weakness. Neurologic: Headache, Memory loss, Incoordination, Depression, Anxiety. 5

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