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Chief Complaint
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Height
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Weight
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Blood Pressure
/
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Pulse
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Temperature
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Respirations
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Oxygen Saturation
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Subjective
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Opiate Use History
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IV Use
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Amount of current Use
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Last Date Used
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History of Treatment
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Overdose
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Cocaine
• • •
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Methadone
• • •
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Opiates
• • •
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Methamphetamine
• • •
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Benzodiazepines
• • •
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Alcohol
• • •
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Marijuana
• • •
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Caffiene
• • •
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Surgical History
• • •
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Last Menstrual Period
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Birth Control
• • •
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Infectious Disease
• • •
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Vaccination Status
• • •
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Living Situation
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Employment Status
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Family History of Substance Abuse
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Mother
• • •
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Father
• • •
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Sibling
• • •
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Grandparent
• • •
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Criminal History
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Psychiatric History
• • •
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Objective
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General
• • •
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Skin
• • •
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HEENT
• • •
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Neck
• • •
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Breasts
• • •
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Cardiovascular
• • •
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Respiratory
• • •
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GI
• • •
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Urinary
• • •
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Genital (Male)
• • •
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Genital (Female)
• • •
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Periph. Vasc.
• • •
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MSK
• • •
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Neurological
• • •
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Endocrine
• • •
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Physical Exam
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General Abnormal
• • •
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HEENT Abnormal
• • •
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Neck Abnormal
• • •
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Cardiovascular Abnormal
• • •
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Lungs Abnormal
• • •
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Abdomen Abnormal
• • •
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MSK Abnormal
• • •
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Skin
• • •
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Neuro Abnormal
• • •
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Extrem Abnormal
• • •
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COWS
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Date
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Time
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Observer
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Resting Pulse Rate: (record beats per minute) Measured after patient is sitting/lying for one minute
• • •
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Sweating: Over past ½ hour not accounted for by room temperature or patient activity.
• • •
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Restlessness: Observation during assessment.
• • •
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Pupil Size:
• • •
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Bone or Joint aches: If patient was having pains previously, only the additional component attributed to opiate withdrawal is s
• • •
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Runny nose or tearing: Not accounted for by cold symptoms or allergies
• • •
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GI Upset: Over last ½ hour
• • •
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Tremor: Observation of outstretched hands
• • •
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Yawning: Observation during assessment
• • •
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Anxiety or Irritability
• • •
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Gooseflesh skin
• • •
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Total Score
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Severity
• • •
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UDS Results
• • •
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HCG Results (If Applicable)
• • •
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DSM-5 Criteria for Diagnosis of Opioid Use Disorder
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Opioids are often taken in larger amounts or over a longer period of time than intended.
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There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
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A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
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Craving, or a strong desire to use opioids.
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Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.
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Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effect
|
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Recurrent opioid use in situations in which it is physically hazardous
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Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have be
|
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Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of opioids to achieve intoxication
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Withdrawal, as manifested by either of the following: (a) the characteristic opioid withdrawal syndrome (b) the same (or a close
|
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Severity
• • •
|
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PLAN
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|
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Opioid Dependence
• • •
|
|
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Education
|
|
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Goals
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|
