Intake History And Physical Page 2
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3Physical Examination:
T_____ P_____ BP_____ R_____ WT_____ HT_____ Gen. Appearance:
HEENT:
ABD
Thyroid/neck
Back
Heart
Neuro
Lungs
Extrem
Chest/breast
Skin
Tracks/scars
Patient Name:
Signs of Opioid Withdrawal:
Date/Time of Last Use:
Pupils
Rhinorrhea
Lacrimation
Perspiration
Pilorection
Increase Temp.
Increase BP
Tachycardia
Vomiting
Diarrhea
Myalgia/Joint Pain
Anxiety
COWS score
Screening Laboratory Results:
Urine Drug Screen Results:
Liver Function Test Results:
Other Labs (CBC, chemistries):
Office-based opioid dependence treatment assessment:
Opioid Dependence
Yes_____
No_____
_____ withdrawal: Degree: None
Minimal
Moderate
Severe
Other Diagnoses:
400 Massasoit Ave. Suite 307, 2nd Flr. | East Providence RI 02914| P: (888) 572-7724 F: (401) 272-0922 | Email:
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