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Tampa Bay Detox

OPIATE DETOX SCREENING FORM - Under construction  

For now go to Patient Info Form

Please enter your information as accurately as possible.

*Your Name:
 
*Patient Name:
*Phone #:
*Address:
*City:
*State:
*Zip:
*Email Address:
*Date of Birth:
*Age:
*Support Person:
*Phone #:
*Referred by:

*Current PCP or Specialist Name:
*Phone #:
*Current Counselor/Psychiatrist Name:
*Phone #:
*Aftercare Treatment Plan:
*Pharmacy Phone #:

*Current Daily Opiate Use:
*Amount Used Daily:
Means of Use:
Snort, IV, Other
*First Opiate Use:
*Age When Started:
*Previous Substance Abuse:
*Previous Drug Treatment:
(when and how long was abstinence?)
*Legal Problems:
*Previous Methadone Use:
Yes, No
*If Yes, How much:
*Other Drug Use in the Past and Currently:
Past:
*Alcohol: rare, mild, heavy
*Cocaine: rare, mild, heavy
*Other: rare, mild, heavy
Present:
*Alcohol: rare, mild, heavy
*Cocaine: rare, mild, heavy
*Other: rare, mild, heavy
*Overdoses (how many):
*Suicide Attempts (how many):
*Past Medical History:
(any cardiac or respiratory problems?)
*Current Medications:
*Allergies to Medications:
Family History:
*Mother (age):
*Father (age):
*Siblings (age):
Family Hx S/A
*MA side:
*PA side:
Family Medical History:
*Mother: (please list any medical conditions or problems)
*Father: (please list any medical conditions or problems)
Social History:
*Married:
*Children:
*Lives with:
*Smoke: (packs per day)
*Pregnant:
*Employment: Full Time, Part Time, Unemployed
*Job Title:
*Job Description:
*Additional Notes Pertaining to Detox:



Note: An * indicates a required field.

 

 

     
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