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Male/Female
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Years Opiate Dependent
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Why Pt Started Using Opiates
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Pt describes opiate use as___
• • •
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Pt describes problem as ___
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It is exacerbated by ____
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It is relieved by____
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Dependence Intensity w/out meds?
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Past Treatment
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Tx's that improved symptoms?
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Modifying Factors
• • •
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Associated Symptoms
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Current Treatment
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Months in Treatment
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Biggest Impact on Recovery
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Current Intensity of Treatment
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Comments
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Duration of Intensity of Treatment
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Comments
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How Many Months Clean
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