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PAST MEDICAL, FAMILY, SOCIAL HISTORIES
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PCP, Referring Provider (as on file)
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Therapist
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Past Medical History
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Past Psychiatric History
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Social History: marriages, children, living arrangements
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Family Med/Psych history
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Occupation/Employment Comments:
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Education Level: (highest,difficulties)
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Military: (service/discharge/rank/traumas)
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Childhood: (ACEs,traumas,life-events)
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Legal: (incarceration/charges/felonies)
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SUBSTANCE USE DETAILED
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Smoking Cessation add-on (3-10 minutes) - add on code: 99406
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Nicotine Use: (start/route/duration/intensity/last)
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Disorder Criteria (nicotine)
• • •
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NICOTINE DEPENDENCE SCALE (FAGERSTROM)
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1. How soon after waking do you smoke your 1st cigarette?
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2. Do you find it difficult to refrain from smoking in places it is forbidden?
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3. Which cigarette would you hate to give up?
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4. How many cigarettes a day do you smoke?
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5. Do you smoke more frequently in the morning?
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6. Do you smoke even if you are sick in bed most of the day?
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FAGERSTROM SUM AND INTERPRETATION
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Alcohol Use: (start/route/duration/intensity/last)
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Disorder Criteria (alcohol)
• • •
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ALCOHOL ABUSE SCALE (AUDIT-C)
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1. How often do you drink?
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2. How many drinks per day when drinking?
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3. How often >/=6 drinks on one occasion?
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Cannabis Use: (start/route/duration/intensity/last)
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Disorder Criteria (cannabis)
• • •
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Sedative/Hypnotic/Anxiolytic Use: (start/route/duration/intensity/last)
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Disorder Criteria (sed/hyp/anx)
• • •
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Opioid Use: (start/route/duration/intensity/last)
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Disorder Criteria (opi)
• • •
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Stimulant Use: (start/route/duration/intensity/last)
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Disorder Criteria (stim)
• • •
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Hallucinogen Use: (start/route/duration/intensity/last)
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Disorder Criteria (hall)
• • •
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Other Substance Use: (start/route/duration/intensity/last)
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Disorder Criteria (other substance)
• • •
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