Alcohol Baseline Progress Note Page 2
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2Alcohol Followup Progress Note
Date:
Time spent:
Patient name:
Heavy drinking days in the past month
days (positive = ≥ 1)
(≥ 5 drinks for men/≥ 4 for women)
Average weekly drinking in the past month
drinks per week
Working diagnosis:
At-risk drinking
Alcohol abuse
Alcohol dependence
Goal:
Drinking within limits
Abstinence
Current medications:
Naltrexone
Acamprosate
Disulfiram
Other (specify):
Interval history and progress:
Physical examination and laboratory:
Assessment:
At-risk drinking
Goals fully met
Alcohol abuse
Goals partially met
Alcohol dependence
Goals not met
Plan:
Repeat screening as needed
Patient education about drinking limits
Recommended drinking within limits
Did the patient agree?
yes
no
Recommended abstinence
Did the patient agree?
yes
no
Naltrexone 50 mg daily
Acamprosate 666 mg 3 times daily
Disulfiram 250 mg daily
XR-Naltrexone injectable
Acamprosate 333 mg 3 times daily (for moderate renal impairment)
Thiamine 100 mg IM/PO
Other medication/dosage:
Referral (specify):
Followup:
Additional plan (withdrawal treatment, coexisting conditions):
Excerpted from NIH Publication No. 06-3769
National Institute on Alcohol Abuse and Alcoholism
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