BC METHADONE PROGRAM
Patient Assessment Form
Date: __________________________________
PATIENT INFORMATION
SURNAME:
GIVEN NAME:
ADDRESS:
CITY:
PHONE:
PHN:
DOB:
METHADONE MD:
CPSID:
PHONE :
FAMILY MD:
PHONE:
CONTACTED:
YYYY
MM
Yes
DD
No
ADMISSION CRITERIA
Current IV heroin
Current heroin snorter
Current heroin smoker
Current other morphine-like user (specify) ______________________________________________________________
Over the age of 21 years (if under 21 years, reasons for initiating therapy should be clearly documented)
ADDITIONAL IMPORTANT FACTORS
Extensive history of opioid use
Tried detox, outpatient, or in-patient treatment during the previous 12 months, and is not willing to try this option again as an
alternative to methadone treatment
Associated medical conditions in current heroin user:
HIV+
AIDS
Hep B +
Hep C+
Other ____________________________
Pregnancy in current heroin user
SUBSTANCE
AMOUNT USED
DAY/WEEK/MONTH
ROUTE
IV, etc.
AGE FIRST
USED
DATE LAST USED
YY/MM/DD
Heroin
Other opioids
Cocaine
Alcohol
Benzos
Nicotine
THC
Other
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Patient name: __________________________________________________________
Date: __________________________________
ASSESSMENT CHECKLIST
Biopsychosocial History
Psychiatric
Overdose history
Mini-mental status exam
Prior drug treatment attempts:
Detox
AA/NA
In-patient treatment
Outpatient treatment
Prior MMP and where: _____________________________________________
______________________________________________
Other addictive problems:
Gambling
Needle
Sex
Crime
High-risk behaviour
Spending
Legal history and current status (pending court charges)
Employment
Financial situation
Other treatment options explored
Medications
Allergies
Systems review
Physical Examination
Laboratory Tests
Urine drug test
Liver function test
BIOPSYCHOSOCIAL HISTORY
Substance Dependence History
DETOX Hx
Facility/outpatient
Abstinence:
DATE STARTED
DURATION
RECOVERY Hx
Facility / NA, AA
DATE STARTED
DURATION
Number of times: _________ Duration: ________________________ Dates: ___________________________
Number of times: _________ Duration: ________________________ Dates: ___________________________
Number of times: _________ Duration: ________________________ Dates: ___________________________
Previous MMT:
No
Yes
If yes, give methadone physician’s name: _________________________________________
Date: _________________________________________
Dose: _________________________________________
Drug costs per day:
< $50
$50 to $100
$100 to $200
> $200
Source of income for drugs:
Welfare/EI
Illegal activity
Sex
Employment
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Patient name: __________________________________________________________
Date: __________________________________
BIOPSYCHOSOCIAL HISTORY continued
Psychological History
1.
Current situation (including crisis or circumstances leading to methadone clinic):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
2.
History of present problem (date and manner of onset, and order of subsequent symptoms):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
3.
Family history, including chemical history:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
4.
Social/emotional support (including living situation):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5.
Support groups:
AA
NA
CA
MA
ACOA
Other
________________________________________________________________________________________________________
________________________________________________________________________________________________________
6.
Legal concerns/charges pending: ____________________________________________________________________________
Probation/parole court date(s): _____________________________________________________________________________
Criminal history: _________________________________________________________________________________________
7.
Employed:
Yes
No
Source and amount of income: _____________________________________________________________________________
8.
Areas of concern for patient, e.g.,
Sexual abuse
Violence
Child at risk
Relapse prevention
Other __________________________________________
__________________________________________
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Patient name: __________________________________________________________
Date: __________________________________
BIOPSYCHOSOCIAL HISTORY continued
Medical History
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Endocarditis ______________________________________
Injection site abscess _______________________________
Seizures__________________________________________
Overdose _________________________________________
Psychiatric history: _____________________________________________________________________________________________
Suicide attempts
Yes
No
Surgical history: _______________________________________________________________________________________________
Meds: _______________________________________________________________________________________________________
Allergies: ____________________________________________________________________________________________________
Review of Systems
EENT
____________________________________________
RESP
________________________________________________
CVS
____________________________________________
GI
________________________________________________
CNS
____________________________________________
ENDO
________________________________________________
STD
____________________________________________
GU
________________________________________________
SKIN
____________________________________________
MSK
________________________________________________
Cycle
________________________________________________
GYNE
G ___________ P ___________
A ____________
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Patient name: __________________________________________________________
Date: __________________________________
PHYSICAL EXAMINATION
Track marks
Signs of recent opioid use
Arms
Legs
Neck
Abdomen
Constricted pupils
Drowsiness
Slurred speech
Unsteady gait
Signs/Symptoms of withdrawal
Arthralgia/myalgia
Dilated pupils
Diaphoresis
Diarrhea
Fever
Goose flesh
Lacrimation
Rhinorrhea
Height ____________ Weight ___________ BP ______________ Pulse __________________ Temperature ______________
ENT
____________________________________________
CHEST
____________________________________________
CVS
____________________________________________
ABD
____________________________________________
M/SK
____________________________________________
Neuro
____________________________________________
Other findings: ________________________________________________________________________________________________
Mini-mental status examination (if applicable):
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
SCREENING
Liver function test
Result ______________________________
Date ______________________________
Urine drug test
Result ______________________________
Date ______________________________
HIV
Result ______________________________
Date ______________________________
Hepatitis B
Result ______________________________
Date ______________________________
Hepatitis C
Result ______________________________
Date ______________________________
Mantoux (when appropriate)
Yes
Result: _________________________________________________________
Syphilis (when appropriate)
Yes
Result: _________________________________________________________
Pregnancy (when appropriate)
Yes
Result: _________________________________________________________
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Patient name: __________________________________________________________
Date: __________________________________
ASSESSMENT (meets criteria for):
SUBSTANCE
DEPENDENCE TO:
Opioids
Cocaine
Nicotine
Alcohol
Benzos
___________________
SUBSTANCE
ABUSE OF:
Opioids
Cocaine
Nicotine
Alcohol
Benzos
____________________
READINESS
TO CHANGE
Recontemplative
Contemplative
Preparation
Action
Relapse
Maintenance
PLAN
MMT
A&D counselling
Detox
Support recovery
Harm reduction
12-step program
Summary:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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Patient Assessment Form continued
Patient name: __________________________________________________________
Date: __________________________________
Treatment Goals and Plan (To be reviewed as clinically required or every Ɛŝdž months)
SHORT-TERM TREATMENT PLAN
DATE
GOAL
PLAN
LONG-TERM TREATMENT PLAN
DATE
GOAL
PLAN
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