Intake History And Physical
Download a blank fillable Intake History And Physical in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Intake History And Physical with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Buprenorphine Treatment
Intake History and Physical
NAME:
DATE:
Chief Complaint:
Opiate use history:
Yrs/mos of use
Route of Admin
Current length of continuous use
Amount of current use
Last use date/time
Present Symptoms
History of drug abuse treatment:
Medical History:
Allergies:
Current med:
Medical/psychiatric problems:
Hospitalization/surgery:
Psychiatric treatment:
Hepatitis
SBE______
HIV_______
TB_______
STD________
(women) LMP______
G____ P____ TAB____ SAB ____ Contraception________________________
ROS:
Other Drug Abuse History:
Cocaine/stimulant:_________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical/Psychiatric Complications of Use:
Alcohol: Current amount:____________________________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical/Psychiatric Complications of Use:
Benzodiazepines:__________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical Complications of Use:
Marijuana:__________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Medical Psychiatric
Complications of Use:
Caffeine: Current Use:__________ Mos/Yrs of Use:_____
Nicotine/cigaretts:__________ Pack years:__________
Nutrition History:
Routine screening history (pap, chol, TB, Hep Panel, HIV, ECG, Pregnancy test, etc.):
400 Massasoit Ave. Suite 307, 2nd Flr. | East Providence RI 02914| P: (888) 572-7724 F: (401) 272-0922 | Email:
|Twitter: @PCSSProjects
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business