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Chief Complaint
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Reason for visit
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Additional Complaints
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Past Addiction History
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Childhood History
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type of abuse
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Adult History
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type of abuse
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Age of first drug use
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Highest Education
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Drugs of Abuse
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DRUGS OF ABUSE USED IN THE PAST
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Additional drug used:
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Method of Abuse
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Known contact with Hepatitis C
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Marital Status
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Employement Status
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Infectious Disease
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Last Menstrual Period
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Birth Control
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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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Associated Psychiatric History
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Psychiatric History
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Review of Systems
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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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Psychiatric ROS
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PHYSICAL EXAMINATION
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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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Current Withdrawal symptoms
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Observer
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PAST Withdrawal symptoms
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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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Post Induction Withdrawal Symptoms
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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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IN HOUSE LABS
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UDS Results
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HCG Results (If Applicable)
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PLAN OF CARE
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Opioid Dependence
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Stage of Change
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Education
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Goals
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