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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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Past addition history has been reviewed.
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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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Childhood Trauma
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Type of Abuse suffered:
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Adult Trauma History
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Type of Abuse suffered:
• • •
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Age of first drug use?
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Highest Education
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COWS
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COWS
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DSM-5 Criteria for Diagnosis of Opioid Use Disorder
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DSM criteria for Addiction
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