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Please update chief complaint above!!!
Subjective
Substance Abuse
Primary substance of abuse
Use onset
Use duration
Frequency
Amount
Last use
Other substance of abuse
Frequency
Amount
Last use
Other substance of abuse
Frequency
Amount
Last use
Taken buprenorphine before?
Obtained buprenorphine from
• • •
Periods of abstinence
Longest
Methods/treatments used
Current Pain Management
Today's pain
Average pain without rx
Average pain with rx
Analgesia
ADLs
Adverse SE
Aberrant Behaviors
Exacerbating
Relieving
Risk of Harm
SI or HI?
Plan
Means
Safety Plan
Describe safety plan
Psychiatric History
Psychiatric history
Diagnosis
Historical medication trials
Current medications
Medical History
Medical history
Diagnosis
Current medications
Surgical history
Seizure history
Allergies
Objective
Vitals
P:
BP:
RR:
Temp:
COWS and/or CIWA Scale
PMP Results Consistent with hx
UDS Results
Labs reviewed
Exam Findings
Physical Exam
General Appearance
Ambulation
• • •
HEENT
• • •
Lung
• • •
Cardiovascular
• • •
Abdomen
• • •
Neuro
• • •
Changes in station
Changes in motor strength
Mental Status Exam
All exam findings WNL
Mood
Speech
Affect
Thought Process
Thought Content
Insight/Judgment
Assessment
Assessment
Plan
Plan
Justification for Program Recommendation
Justification for program recommendation
• • •
Recommended Phase of Treatment
Recommended phase of treatment
• • •
Medication Consent and Patient Safety
Medication Consent and Patient Safety
• • •

Physician Intake Medical Form

Counselor

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Published: Feb. 5, 2018, 1:46 p.m.
Doctor: Dr. History Physical
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