The Opiate Treatment Index (OTI)
|
|
- Gerald Carr
- 8 years ago
- Views:
Transcription
1 The Opiate Treatment Index (OTI) (Drug use, criminality and health status components) Adapted from: Darke, S., Ward, J., Hall, W., Heather, N. & Wodak, A. (1991). The Opiate Treatment Index (OTI) Researcher's Manual. National Drug and Alcohol Research Centre Technical Report Number 11. Sydney: National Drug and Alcohol Research Centre
2 OPIATE TREATMENT INDEX (OTI) Part 1: DRUG USE First, I'm going to ask you some questions on your use of drugs. I'll emphasise again that the information you give me is completely confidential. [Note: For all categories, if the subject responds that their last use of the drug was more than a month ago, score zero for that category. Do not include use on day of interview.] Heroin Now I'm going to ask you some questions about heroin (smack, hammer, horse, scag, etc.). 1. How many days ago did you last use heroin? / 2. How many hits, smokes, snorts, etc. did you have on that day? / 3. How many days before that did you use heroin? / 4. And how many hits, smokes, snorts, etc. did you have on that day? / 5. And when was the day before that? / Other Opiates These questions are about your use of opiates other than heroin (e.g. street methadone, morphine, pethidine, codeine) 6. How many days ago did you last use opiates other than heroin? (do not include legally obtained methadone) / 7. How many pills, doses, etc. did you have on that day? / 8. How many days before that did you use opiates other than heroin? / 9. And how many pills, doses etc. did you have on that day? / 10. And when was the day before that? /
3 Cannabis These questions are about your use of marijuana (cannabis, dope, grass, hash, pot, etc.). 11. How many days ago did you last use marijuana? / 12. How many joints, bongs, etc. did you have on that day? / 13. How many days before that did you use marijuana? / 14. And how many joints, bongs, etc. did you have on that day? / 15. And when was the day before that? / Amphetamines These questions are about your use of amphetamines (speed). 16. How many days ago did you last use amphetamines? / 17. How many tablets, snorts, hits, etc. did you have on that day? / 18. How many days before that did you use amphetamines? / 19. And how many tablets, snorts, hits, etc. did you have on that day? / 20. And when was the day before that? / Cocaine These questions are about your use of cocaine (coke, snow, crack, etc.). 21. How many days ago did you last use cocaine? / 22. How many snorts, hits, smokes, etc. did you have on that day? / 23. How many days before that did you use cocaine? / 24. And how many snorts, hits, smokes, etc. did you have on that day? / 25. And when was the day before that? / Benzodiazepines These questions are about your use of tranquillisers (e.g. benzos, Serepax, Rohypnol, Mogadon, Valium). 26. How many days ago did you last use tranquillisers? / 27. How many pills did you have on that day? / 28. How many days before that did you use tranquillisers? / 29. And how many pills did you have on that day? / 30. And when was the day before that? /
4 Barbiturates These questions are about your use of barbiturates (e.g. Nembutal, Seconal,etc.). 31. How many days ago did you last use barbiturates? / 32. How many pills did you have on that day? / 33. How many days before that did you use barbiturates? / 34. And how many pills did you have on that day? / 35. And when was the day before that? / Hallucinogens These questions are about your use of hallucinogens (e.g. LSD/acid, ecstasy, magic magic mushrooms). 36. How many days ago did you last use hallucinogens? / 37. How many tabs, pills, etc. did you have on that day? / 38. How many days before that did you use hallucinogens? / 39. And how many tabs, pills, etc. did you have on that day? / 40. And when was the day before that? / Inhalants These questions are about your use of inhalants (e.g. amyl nitrite/rush, glue, laughing gas, aerosols, petrol). 41. How many days ago did you last use inhalants? / (do not include asthma sprays) 42. How many sniffs did you have on that day? / 43. How many days before that did you use inhalants? / 44. And how many sniffs did you have on that day? / 45. And when was the day before that? / Tobacco Finally, these questions are about your use of cigarettes. 46. How many days ago did you last use tobacco? / 47. How many cigarettes did you have on that day? / 48. How many days before that did you use tobacco? / 49. And how many cigarettes did you have on that day? / 50. And when was the day before that? /
5 General Comments On Drug Use DRUG USE SUMMARY: Q SCORES a. Heroin f. Benzodiazepines b. Other Opiates g. Barbiturates c. Cannabis h. Hallucinogens d. Amphetamines i. Inhalants e. Cocaine j. Tobacco
6 Part 2: CRIME In this section I am interested in any crimes that you may have committed. Any information that you give here is completely confidential. [Give Response Card to participant] Property Crime First, I am going to ask you some questions on property crime. By property crime I mean things such as break and enter, robbery without violence, shoplifting, stealing a prescription pad, stealing a car, or receiving stolen goods. I am interested in the number of times that you committed a property crime, not the number of times you've been caught. 1. How often, on average, during the last month have you committed a property crime? Dealing 0 No property crime 1 Less than once a week 2 Once a week 3 More than once a week (but less than daily) 4 Daily Now I am going to ask you some questions about dealing. By dealing I mean selling drugs to someone. I am interested in the number of times that you've dealt drugs, not the number of times you've been caught. 2. How often, on average, during the last month have you sold drugs to someone? Fraud 0 No drug dealing 1 Less than once a week 2 Once a week 3 More than once a week (but less than daily) 4 Daily Now I am going to ask you some questions about fraud scams. By fraud I mean things such as forging cheques, forging prescriptions, social security scams, or using someone else's credit card. I am interested in the number of times that you've committed fraud, not the number of times that you've been caught. 3. How often, on average, during the last month have you committed a fraud? 0 No fraud 1 Less than once a week 2 Once a week 3 More than once a week (but less than daily) 4 Daily
7 Crimes Involving Violence Finally, I am going to ask you some questions about crimes involving violence. By crimes involving violence I mean things such as using violence in a robbery, armed robbery, assault, rape, etc. I am interested in the number of times that you've committed a crime involving violence, not the number of times that you've been caught. 4. How often, on average, during the last month have you committed a crime involving violence? 0 No violent crime 1 Less than once a week 2 Once a week 3 More than once a week (but less than daily) 4 Daily CRIME TOTAL: Part 3: HEALTH These questions are about your health. I am going to read out a list of health problems. Please answer Yes if you have had any of these problems over the last month. [Note: Circle Yes or No responses as indicated by participant, and count the number of Yes responses in each group of symptoms to give a sub-total] 1. General a. fatigue/energy loss Yes No b. poor appetite Yes No c. weight loss/underweight Yes No d. trouble sleeping Yes No e. fever Yes No f. night sweats Yes No g. swollen glands Yes No h. jaundice Yes No i. bleeding easily Yes No j. teeth problems Yes No k. eye/vision problems Yes No l. ear/hearing problems Yes No m. cuts needing stitches Yes No N. SUB-TOTAL
8 2. Injection Related Problems a. overdose Yes No b. abscesses/infections from injecting Yes No c. dirty hit (made feel sick) Yes No d. prominent scarring/bruising Yes No e. difficulty injecting Yes No F. SUB-TOTAL 3. Cardio/Respiratory a. persistent cough Yes No b. coughing up phlegm Yes No c. coughing up blood Yes No d. wheezing Yes No e. sore throat Yes No f. shortness of breath Yes No g. chest pains Yes No h. heart flutters/racing Yes No i. swollen ankles Yes No J. SUB-TOTAL 4. Genito-urinary a. painful urination Yes No b. loss of sex urge Yes No c. discharge from genitals Yes No d. rash on/around genitals Yes No E. SUB-TOTAL 5. Gynaecological (WOMEN ONLY) (in the last few months) a. irregular period Yes No b. miscarriage Yes No C. SUB-TOTAL
9 6. Musculo-skeletal a. Joint pains/stiffness Yes No b. Broken bones Yes No c. Muscle pain Yes No D. SUB-TOTAL 7. Neurological a. headaches Yes No b. blackouts Yes No c. tremors (shakes) Yes No d. numbness/tingling Yes No e. dizziness Yes No f. fits/seizures Yes No g. difficulty walking Yes No h. head injury Yes No i. forgetting things Yes No J. SUB-TOTAL 8. Gastro-intestinal a. nausea Yes No b. vomiting Yes No c. stomach pains Yes No d. constipation Yes No e. diarrhoea Yes No F. SUB-TOTAL HEALTH TOTAL:
10 Response Card OTI (Part 2: Questions 1 4) None Less than once a week Once a week More than once a week (but less than daily) Daily
ALCOHOL AND DRUG USE ASSESSMENT
ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) Source: The items are from the ASSIST Scale. Public Domain Reference: WHO ASSIST Working Group (2002). The Alcohol, Smoking and Substance
More informationSUBSTANCE USE QUESTIONNAIRE. Name: Date: Ever Used? Ever a Problem? Age of 1 st Use When last used?
SUBSTANCE USE QUESTIONNAIRE Name: Date: Part I. Substance Abuse History Ever Used? Ever a Problem? Age of 1 st Use When last used? Alcohol Yes No Yes No Barbiturates or Yes No Yes No other sleeping pills
More informationDRUG USE. 1300 136 588 ndss.com.au AND TYPE 1 DIABETES
DRUG USE AND TYPE 1 DIABETES 1300 136 588 ndss.com.au The National Diabetes Services Scheme (NDSS) is an initiative of the Australian Government administered by Diabetes Australia. Contents Topic Page
More informationAddiction Medical Clinic LLC
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
More information34 th Judicial District Substance Abuse Study Guide
34 th Judicial District Substance Abuse Study Guide What is Drug Addiction? 2 It is characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that
More informationApplication For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
More informationWomen s Continence and Pelvic Health Center
Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire
More informationEmory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions
More informationPATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
More informationWhat you need for Your to know Safety about longterm. opioid pain care. What you need to know about long-term opioid
What you need to know about longterm opioid pain care. What you need to know about long-term opioid and the Safety of Others pain care. TAKING What you OPIOIDS need to know about long-term RESPONSIBLY
More informationInterventional Spine Care New Patient History and Intake Form
Interventional Spine Care New Patient Introduction You have been referred to Dr. Hamburger/Dr. Olson. Our focus is the evaluation and management of low back pain, and other disorders of the spine. Our
More informationPastoral Care Team BELB
Pastoral Care Team BELB Prevention Education Laws by-laws and guidelines Resources; human and financial Treatment and rehabilitation N. Ireland Drug Trends Almost half of young people are likely to take
More informationPharmacy and supermarket drugs
Pharmacy and supermarket Benzodiazepines Stimulants Tobacco drugs 185 8 Pharmacy and supermarket drugs Overview Over-the-counter medicines Prescribed medicines that are misused or sold on the streets Alcohol-based
More informationDenver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine
More informationLighthouse IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY.
Lighthouse Chiropractic IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY. Your Auto Insurance Company Name Address Policy
More informationJAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
More informationLike cocaine, heroin is a drug that is illegal in some areas of the world. Heroin is highly addictive.
Heroin Introduction Heroin is a powerful drug that affects the brain. People who use it can form a strong addiction. Addiction is when a drug user can t stop taking a drug, even when he or she wants to.
More informationNorth Carolina Orthopaedic Clinic Patient Registration Form
North Carolina Orthopaedic Clinic Patient Registration Form FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY PATIENT INFORMATION NAME: BIRTHDATE: AGE: TODAY S DATE: SOCIAL SECURITY
More informationOVERVIEW WHAT IS POLyDRUG USE? Different examples of polydrug use
Petrol, paint and other Polydrug inhalants use 237 11 Polydrug use Overview What is polydrug use? Reasons for polydrug use What are the harms of polydrug use? How to assess a person who uses several drugs
More informationKnow the facts about drugs
Know the facts about drugs What do you know about drugs? What would you do if you thought someone you cared about was using drugs? What would you do if you were offered drugs? How would you react if you
More informationSt. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
More informationDRUGS OF ABUSE CLASSIFICATION AND EFFECTS
Drug and Drug use DRUGS OF ABUSE CLASSIFICATION AND EFFECTS A pharmaceutical preparation or a naturally occurring substance used primarily to bring about a change in the existing process or state (physiological,
More informationDANGERS OF. f HEROIN. ALERT s alert
AKA > Smack, H, hammer, skag, horse, dope, rocks... WHAT IS HEROIN? Heroin comes from the opium poppy. 1 Heroin is sold as white granules, pieces of rock or powder with a bitter taste and no smell. It
More informationThis booklet provides information for people who use heroin The National Drug and Alcohol Research Centre (NDARC) has conducted many interviews with
This booklet provides information for people who use heroin The National Drug and Alcohol Research Centre (NDARC) has conducted many interviews with heroin users, many of whom have requested more information
More informationDrug Abuse Pre-reading Activity
Drug Abuse Pre-reading Activity Discussion Questions Discuss the following statements. Do you think they are true or false? There is not a drug problem in the UAE. Tobacco is more addictive than heroin.
More informationAnd, despite the numbers, for many people, the Facts About Drugs are not clear.
According to the National Survey on Drug Use and Health (NSDUH), an estimated 20 million Americans aged 12 or older used an illegal drug in the past 30 days. This estimate represents 8% percent of the
More informationSLEEP QUESTIONNAIRE AND WAKEFULNESS
SLEEP QUESTIONNAIRE AND WAKEFULNESS (SQAW) PATIENT: DOCTOR: DATE COMPLETED: Must Be Completed by Appointment Date 7423-029-W-BKLT 11-1-09 For questions to be answered on a scale of 1 to 5, please circle
More informationPOINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
More informationShare the important information in this Medication Guide with members of your household.
MEDICATION GUIDE BUPRENORPHINE (BUE-pre-NOR-feen) Sublingual Tablets, CIII IMPORTANT: Keep buprenorphine sublingual tablets in a secure place away from children. Accidental use by a child is a medical
More informationDRUGS AND ALCOHOL. Intent
DRUGS AND ALCOHOL Intent With the health, safety and welfare of our students of paramount importance, Health and Drug Education Programs have been designed to assist students make responsible and informed
More informationPATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)
REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please
More informationThe NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792 1 PAIN MANAGEMENT SERVICES New Patient Questionnaire Date: Primary MD: Referring
More informationGet the Facts About Tuberculosis Disease
TB Get the Facts About Tuberculosis Disease What s Inside: Read this brochure today to learn how to protect your family and friends from TB. Then share it with people in your life. 2 Contents Get the facts,
More informationOTC Abuse. Dr. Eman Said Abd-Elkhalek Lecturer of Pharmacology & Toxicology Faculty of Pharmacy Mansoura University
OTC Abuse Dr. Eman Said Abd-Elkhalek Lecturer of Pharmacology & Toxicology Faculty of Pharmacy Mansoura University Opiates Abuse Opioids are a group of natural, partially synthetic, or synthetic drugs
More informationINTAKE ASSESSMENT. 1. Print out the Intake Assessment or call ARISE Alcohol Recovery to have an assessment mailed to you.
INTAKE ASSESSMENT Directions: Please complete all sections of the attached Intake Assessment form with as much accuracy as possible. You may have someone who knows you well assist you with completing the
More informationCervical Spine. New Patient Form
Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right
More informationIt is important that you tell your family and the people closest to you of this increased sensitivity to opioids and the risk of overdose.
MEDICATION GUIDE VIVITROL (viv-i-trol) (naltrexone for extended-release injectable suspension) Read this Medication Guide before you start receiving VIVITROL injections and each time you receive an injection.
More informationLegal and Illegal Drugs. Drug is any chemical that causes changes in a person s body or behavior.
Legal and Illegal Drugs Drug is any chemical that causes changes in a person s body or behavior. Legal Drug is a drug that is permitted by law. Illegal Drug are chemicals that are unlawful because their
More informationA prisoners guide to buprenorphine
A prisoners guide to buprenorphine 2 The Opium poppy In the land of far, far away the opium poppy grows. The seed pods of this poppy are scratched until they drip with a sticky resin called opium. Raw
More informationMOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
More informationDrug and Alcohol Use Survey
Drug and Alcohol Use Survey Name Date Directions: Please circle one response for each question. 1. How old were you when you had your first drink of alcohol other than a few sips? a. I have never had a
More informationSUBSTANCE MISUSE IN PREGNANCY. An Information Booklet
SUBSTANCE MISUSE IN PREGNANCY An Information Booklet Contents Introduction... 2 Planning a baby... 3 What should I do if I think I am pregnant?... 4 Drugs and their effects on the pregnancy... 5 1) Heroin...
More informationDrug and Alcohol Abuse Training revised: October 2015
Drug and Alcohol Abuse Training revised: October 2015 FMCSA is considering going to a seven panel and possibly ten panel. Hair testing may also be acceptable. What is a Drug? A substance which
More informationDriving Impairment by Alcohol and Drug
Asian sian Center enter for Transportations Studiestudies Driving Impairment by Alcohol and Drug Road Safety Engineering Training 26 30 June 2006 Why are road injuries important? Potential years of life
More informationDowners/Depressants (pages 40-50)
Downers/Depressants (pages 40-50) Read pages 49-54, 59-60, and 78-79 of the booklet, Street Drugs. Pages 40-50 of the text. Narcotics: Prescription Origin: Southeast Asia, Southwest Asia, and in the Western
More informationSUPERVISOR'S MANUAL FOR DRUG & ALCOHOL TESTING
SUPERVISOR'S MANUAL FOR DRUG & ALCOHOL TESTING Gulf South Resources, Inc 410 E. Laurel Foley, AL 36535 251-943-4717 For supervisors, the omnibus act involves special attention. It is the supervisors responsibility
More informationListed below are some of the reasons given by users to describe why they take drug(s): An escape from problems, either at home, school or work.
Once drug use comes into the equation, inhibitions that normally protect the individual effectively go out of the window and leave the user feeling high or buzzing. Situations, incidents or behaviours
More informationDrugs and their effects. English
Drugs and their effects English Common drug terms Depressant drug A type of drug which slows down (depresses) the functions of the body, including the messages to and from the brain. Depressant drugs include
More informationNEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
More informationDrug addiction. These factors increase the likelihood of your having an addiction to a legal or an illegal drug:
Drug addiction You may be hooked emotionally and psychologically. You may have a physical dependence, too. If you're addicted to a drug whether it's legal or illegal you have intense cravings for it. You
More informationTreatments for drug misuse
Understanding NICE guidance Information for people who use NHS services Treatments for drug misuse NICE clinical guidelines advise the NHS on caring for people with specific conditions or diseases and
More informationRoutes of Use. Overdose and EMS. Injection. Ingestion. Inhalation. Absorption 1/2/2013. Injection Ingestion Inhalation Absorption.
Routes of Use Overdose and EMS Injection Ingestion Inhalation Absorption Shaun Pitts, AEMT Venomous bites Common drugs Heroin Cocaine Meth Injection Ingestion Cleaning solutions Household plants Medications
More informationMEDICATION GUIDE WELLBUTRIN (WELL byu-trin) (bupropion hydrochloride) Tablets
MEDICATION GUIDE WELLBUTRIN (WELL byu-trin) (bupropion hydrochloride) Tablets Read this Medication Guide carefully before you start using WELLBUTRIN and each time you get a refill. There may be new information.
More informationCORE ADDICTION ASSESSMENT / ADMISSION PACKAGE. Date of Birth: Day Month Year
Windsor Addiction Assessment & Outpatient Service Tayfour Campus, Withdrawal Management & Assessment Centre 1453 Prince Road, Windsor, Ontario N9C 3Z4 Phone: 519-257-5220 Fax: 519-257-5235 CORE ADDICTION
More informationDrug Abuse and Addiction
Drug Abuse and Addiction Introduction A drug is a chemical substance that can change how your body and mind work. People may abuse drugs to get high or change how they feel. Addiction is when a drug user
More informationGet the Facts About. Disease
Get the Facts About TB TUBERCULOSIS Disease What s Inside: 3 PAGE Get the facts, then get the cure 4 PAGE 9 PAGE 12 PAGE Learn how TB is spread Treatment for TB disease Talking to family and friends about
More informationRehabilitation Medicine Clinic. New Patient Questionnaire
Rehabilitation Medicine Clinic (Please complete this 5-page form and bring to your appointment.) Date Appt. Date Age Date of Birth Name Male Female Hand dominance: R L Home Address Home Phone ( ) Work
More informationGDC Session #1 Symptoms of Cocaine Addiction
GDC Session #1 Symptoms of Cocaine Addiction Objectives of Session 1. Define cocaine addiction as a biopsychosocial disease. 2. Identify the symptoms of addiction that clients have experienced. 3. Identify
More informationGeneral Internal Medicine Clinic New Patient Questionnaire
General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:
More informationOverall Learning Objectives
Overall Learning Objectives Understand the difference between use, misuse and abuse of substances/drugs; Differentiate between commonly abused legal and illegal substances/drugs; Become aware of common
More informationDrug and Alcohol Abuse Prevention Program
Drug and Alcohol Abuse Prevention Program D. A. Dorsey Educational Center is committed to providing a safe and healthy learning environment for all our faculty, staff, and students. Our institution recognizes
More informationWhat you should know about treating your pain with opioids. Important information on the safe use of opioid pain medicine.
What you should know about treating your pain with opioids Important information on the safe use of opioid pain medicine. If your healthcare provider has determined that opioid therapy is right for you,
More informationFeeling that you have to use the drug regularly this can be daily or even several times a day. Failing in your attempts to stop using the drug
Drug addiction Definition Drug addiction is a dependence on an illegal drug or a medication. When you're addicted, you may not be able to control your drug use and you may continue using the drug despite
More informationmethadonefact.qxd 8/11/01 2:05 PM Page 1 INFORMATION Advantages of methadone treatment DEPRESSANT Methadone maintenance Pregnancy METHADONE
methadonefact.qxd 8/11/01 2:05 PM Page 1 INFORMATION Advantages of methadone treatment 10 DEPRESSANT Methadone maintenance Pregnancy METHADONE methadonefact.qxd 8/11/01 2:05 PM Page 2 WHAT IS METHADONE
More informationPlease fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
More informationPATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
More informationSUBSTANCE ABUSE. Key Concepts. Types of Drugs
SUBSTANCE ABUSE You have to choose who you want to be in life. This happens by making lots of decisions every day. Using substances is a choice. This is a big choice, because substances have a very real
More informationNEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
More informationLOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
More informationDallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
More informationSouthlake Psychiatry. Suboxone Contract
Suboxone Contract Thank you for considering Southlake Psychiatry for your Suboxone treatment. Opiate Addiction is a serious condition for which you may find relief with Suboxone treatment. In order to
More informationPATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (Please Print) Name: LAST FIRST Ml Street Address: STREET APT CITY STATE ZIP Home Phone #: ( ) ) Cell Phone #: ( ) ) Social Security #: Birth date: Age: Sex: M ; F Marital Status:
More informationPneumonia Education and Discharge Instructions
Pneumonia Education and Discharge Instructions Pneumonia Education and Discharge Instructions Definition: Pneumonia is an infection of the lungs. Many different organisms can cause it, including bacteria,
More informationAlcohol and drug abuse
Alcohol and drug abuse This chapter explores how alcohol abuse affects our families, relationships, and communities, as well as the health risks associated with drug and alcohol abuse. 1. Alcohol abuse
More informationThe Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM
The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM Personal Information Date: Name: Phone #: Cell #: May we leave a message on these numbers?: Best time to reach me
More informationNew Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
More informationBenzodiazepines. And Sleeping Pills. Psychological Medicine
Benzodiazepines And Sleeping Pills Psychological Medicine Introduction Benzodiazepines are a type of medication prescribed by doctors for its therapeutic actions in various conditions such as stress and
More informationPATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient
PATIENT INFORMATION Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address Emp. Phone Spouse/Partner
More informationLesson 7: Respiratory and Skeletal Systems and Tuberculosis
Glossary 1. asthma: when the airways of the lungs narrow, making breathing difficult 2. bacteria: tiny living creatures that can only be seen with a microscope; some bacteria help the human body, and other
More informationFlorida Digestive Specialists Gastroenterology and Liver Disease Management Over 30 Years of Service
It is a pleasure to welcome you to Florida Digestive Specialists (Formerly Gastroenterology and Oncology Associates)! We strive to exceed your expectations and provide you with the best service possible.
More informationALPHA RECOVERY CENTERS Application & Screening Data
ALPHA RECOVERY CENTERS Application & Screening Data I am applying for admission to: Alpha Recovery Centers Atlanta Alpha Recovery Centers - Brunswick Thank you for your interest in Alpha Recovery Centers.
More informationDrug Free Schools and Communities Act
Drug Free Schools and Communities Act In compliance with the Drug Free Schools and Communities Act and its implementing regulations (34 CFR Part 86), the following information is being provided to all
More informationSample Patient Agreement Forms
Sample Patient Agreement Forms Introduction This resource includes two sample patient agreement forms that can be used with patients who are beginning long-term treatment with opioid analgesics or other
More informationRelation Address City State Zip Code
To enable us to provide you with the best possible care, please complete the following: Date: Name Social Security # First Full Middle Last Address City Zip Code_ Telephone (home) (work) Date of Birth
More informationYouth Alcohol, Tobacco and Drug Use
Attitude and Perception Survey on Youth Alcohol, Tobacco and Drug Use Sponsored by: Northeast Center for Healthy Communities Lawrence, Massachusetts INTRODUCTION TO ATTITUDE AND PRECEPTION SURVEY This
More informationLiving a Full Life with Fibro 60 Day Action Plan
Living a Full Life with Fibro 0 Action Plan In preparation for a visit to your physician, take the time to complete the 0 Action Plan for fibromyalgia, which can provide you and your physician with a better
More informationPatient Registration Form Please print clearly and complete all items. Patient First Name. Street Address. City State Zip
Oakland Orthopedic Partners, P.C., offices of Bruce T. Henderson Paul C. Lewis 44555 Woodward Ave., Ste 406 & 407 Pontiac, MI 48341 Office 248.334.0524 Fax 248.858.3887 www.oaklandorthopedic.com Patient
More informationNEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
More informationPulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
More informationPlano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
More informationSMU Drug Free Schools and Campuses Information for New Employees
SMU Drug Free Schools and Campuses Information for New Employees UNIVERSITY POLICIES: Student Code of Conduct Human Resources - Controlled Substance Abuse in the Workplace Employee Assistance RISKS ASSOCIATED
More information1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
More informationALCOHOL CANNABIS AMPHETAMINES ECSTASY
Where can I get further information or help? In case of emergency involving the use of any drug, ring 000 for an ambulance, or call a hospital or doctor. FREQUENTLY ASKED QUESTIONS Alcohol and Drug Information
More informationInterventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?
More informationPATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
More informationSometimes people live in homes where a parent or other family member drinks too
Alcohol and Drugs What If I'm Concerned About Someone Else's Drinking? Sometimes people live in homes where a parent or other family member drinks too much. This may make you angry, scared, and depressed.
More informationPolicy. Drug- Free School and Communities Act
Policy In keeping with Mid- America Christian University s (MACU) commitment to provide a safe and healthy academic and work environment, the University maintains a drug and alcohol free campus. The University
More informationDown the Up Staircase
Down the Up Staircase Addiction is only a few steps away Supplemental Information on Oxycontin/Heroin Abuse Past & present youth trends? Then Cigarettes Alcohol Marijuana + Now OxyContin Heroin Why do
More informationStaying on Track with TUBERCULOSIS. Medicine
Staying on Track with TB TUBERCULOSIS Medicine What s Inside: Read this brochure to learn about TB and what you can do to get healthy. Put it in a familiar place to pull out and read when you have questions.
More information