Affordable & Restorative Health Care
Winston Griner Sr. M.D
Explanation of Treatment
When you leave the office, the doctor will likely give you a prescription that will last you until your next
appointment which will be in 28 days. The doctor may also want to discuss counseling with you, since
medication plus counseling has been shown to produce better results. At the same time, your doctor
may suggest enrolling in the Here to Help Program, which can provide you with an added support
system. Your doctor will ask you to keep a record of any medication you take at home to control
withdrawal symptoms. You will also receive instruction on how to contact your doctor in an emergency
as well as additional information about treatment. Please bring lab, diagnostic history & physical, last 2
visit or discharge pharmacy print of last
Checklist for First Visit:
 Arrive experiencing moderate opioid withdrawal symptoms
 Arrive prepared to give a urine sample for screening
 Bring completed forms
 Bring all medication bottles/ wrappers
 Co-pay/Full fee due at the time of visit (Cash, Debit/Credit Card or Money Order)
 On time (Affordable and Restorative Healthcare Web site complete forms and print out)
Please see your doctor or pharmacist for full product information for your medicine.
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Explanation of Treatment
Suboxone (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet /films/ bunavil / zubsolv
Intake
You will be given a comprehensive substance dependence assessment, as well as evolution of mental
status and physical exam. The pros and cons of the medication, SUBOXONE, will be presented.
Treatment expectations, as well as issues involved with maintenance versus medically supervised
withdrawal will be discussed.
Induction
You will be switched from your current opioid (heroin, methadone or prescription painkillers) on to
SUBOXONE.at the time of induction, you will be asked to provide a urine sample to confirm the presence
of opioids and possibly other drugs. You must arrive for the visit experiencing mild to moderated opioid
withdrawals symptoms. Arrangements will be made for you to receive your first doses prescription /you
are taking buprenorphine/naloxone. Your response to the initial dose will be monitored. You may
receive additional medication, if necessary, to reduce withdrawal systems.
Since an individual’s tolerance and reaction to SUBOXONEFILMS/ BUNAVIL / ZUBSOLV vary, daily
appointments may be scheduled and medications will be adjusted until you no longer experience
withdrawal symptoms or cravings. Urine drug screening is typically required for all patients at every visit
during this phase.
Intake and induction may both occur at the first visit, depending on your needs and your doctor’s
evaluation.
Stabilization
Once the appropriate are of SUBOXONEFILMS/ BUNAVIL / ZUBSOLV is established, you will stay at this
does until steady blood levels are achieved. You and your doctor will discuss your treatment options
from this point forward.
Maintenance
Treatment compliance and progress will be monitored. Participation in some form of behavioral
counseling is strongly recommended to ensure best chance of treatment success. You are likely to have
scheduled appointments on a weekly basis, however, if treatment progress is good and goals are met,
monthly visit will eventually be considered sufficient. The maintenance phase can last from weeks to
year-the length of treatment will be determined by you and your doctor, and, possibly, your counselor.
Your length of treatment will vary depending on you individual needs.
Medically Supervised Withdrawal
As your treatment progresses ,you and your doctor may eventually decide that medically supervised
withdrawal is an appropriate option for you.in this phase, your doctor will gradually taper your
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SUBOXONEFILMS/ BUNAVIL / ZUBSOLV dose over time, taking care to see that you do not experience
any withdrawal symptoms or cravings. (i.e.: 2 one day 1 ¾ next day then 2 next day 1 ¾)
Explanation of First Visit
Your first visit is generally the longest, and may last anywhere from 1 to 4 hours. When preparing for
your first visit, there are a couple of logistical issues you may want to consider:


You may not want to return to work on the day of your visit-this is very normal, so just plan
accordingly.
Because the medication can cause drowsiness and slow reaction times, particularly during the
first few weeks of treatment, you may want to make arrangements for a ride home.
It is very important to arrive for your first visit already experiencing moderate opioid withdrawal
symptoms. If you are in withdrawal, the medicine is supposed to help lessen the symptoms. However, if
you are not in withdrawal, the medicine will “override” the opioid already in your system, which will
cause severe withdrawal symptoms.
The following guidelines are provided to ensure you re in withdrawal for the visit.(if this concerns you, it
may help to schedule your first visit in the morning ; some patients find it easiest to skip what would
normally be their first dose of the day)


No methadone or long-acting painkillers for at least 24 hours
No heroin or short-acting painkillers for at least 4 to 6 hours
Bring ALL medication bottles with you to your first appointment.
Before you can be seen by the doctor, all of the paperwork your doctor provided must be completed. If
your doctor provided the paperwork to you prior to this visit, bring it completed or arrive about 30
minutes early to fill it out.
Urine drug screening is a regular procedure of treatment, because it provides physicians with important
insight into your health and your treatment. Your first visit will include urine drug screening, and may
also entail an alcohol test and blood work. If you haven’t had a recent physical exam, your doctor may
require one. To help ensure that this medicine is the best treatment option for you, your doctor will
perform a substance dependence assessment and mental status evaluation. Lastly, you and your doctor
will discuss the medicine and your expirations of treatment.
After this portion of your visit is completed, will write a prescription to be giving to a pharmacy. Your
doctor may have you fill the prescription at the pharmacy. If any problems occur go to the emergency
room
Once you take your fist dose, you should begin to feel better within 30 minutes. It’s important that you
are honest about how you are feeling during induction+ so your doctor can find the appropriate does for
you.
+ SUBOXONEFILMS/ BUNAVIL / ZUBSOLV (buprenorphine and naloxone) sublingual films (CIII) is not indicated for induction
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Frequent asked Questions
Risk Evaluation and Mitigation Strategy (REMS)
WHAT IS A RISK EVALUATION AND MITIGATION STRATEGY?
A REMS is a strategy to manage a know or potential risk associated with a drug. A REMS can include
among other strategies, a medication Guide a communication Plan and elements to assure safe use.
IS THERE A REMS FOR SUBOXONEFILMS/ BUNAVIL / ZUBSOLVREMS?
The goals of the REMS for SUBOXONEFILMS/ BUNAVIL / ZUBSOLV are to:
1. Minimizes the risk of accidental overdose ,misuse, and abuse
2. Inform physician ,pharmacists and patient of the serious risk associated with the use of
SUBOXONE
WHAT IS MY ROLE WITH REGARDS TO THE REMS FOR SUBOXONE?
To meet the requirements of the REMS and to ensure the benefits of prescribing SUBOXONEFILMS/
BUNAVIL / ZUBSOLV to a patient outweigh the risk of accidental overdose, misuse and abuse ,physicians
should take the following measures and documents action taken with patient to ensure safe use
conditions.











Verify patient meets diagnostic criteria for opioid dependence
Discuss the risk associated with SUBOXONE, including those described in the medication guide
Provide induction doses under appropriate supervision
Prescribe a limited of medication during the initial stage of treatment
Explain how to safely store the medication
Schedule patient appointment commensurate with patient stability weekly or more frequent
visit recommended for the first month
Consider pill Count/dose reconciliation
Assess whether patient is receiving counseling / psychosocial support considered necessary for
treatment
Assess whether patient is making progress toward treatment goal including as appropriate
,urine toxicology testing
Continually assess appropriateness of maintenance dose
Continually assess whether or not benefits of treatment outweigh the risk
As part of the REMS, physicians prescribing SUBOXONEFILMS/ BUNAVIL / ZUBSOLV for opioid
dependence will be provided with an appropriate use checklist to document safe use condition and
clinical monitoring of each patient. This can be retained in the records of each patient.
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This REMS does not patients admitted to opioid treatment dispensed to patient admitted to opioid
treatment programs under 42 CFR part 8 because the care of these patient is subject to specific
requirements under those regulations.
Frequently Asked Questions: Patients
SUBOXONE (buprenorphine HCI/naloxone HCI dehydrate) Sublingual tablet films/ bunavil / zubsolv,
1. Why do I have to feel sick to start the medication for it to work best?
When you first dose of SUBOXONE, if you ready have a high levels if another opioid in your
system, the SUBOXONE will compete with those opioid molecules and replace them at the
receptor sites. Because SUBOXONEFILMS/ BUNAVIL / ZUBSOLV has a milder opioid effect than
full agonist opioid, you may go into a rapid opioid withdrawal and feel sick, a condition which is
called “precipitated withdrawals.”
By already being in mild to moderate withdrawal when you take your first does of SUBOXONE,
the medication will make you feel noticeably better, not worse.
2. How does SUBOXONEFILMS/ BUNAVIL / ZUBSOLV work?
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV bind to the same receptors as other opioid drugs. It
mimics the effects of other opioids by alleviating carving and withdrawal symptoms. This allows
you to address the psychosocial reason behind your opioid use.
3. When will I start to feel better?
Most patient feel a measurable improvement by 30 minutes to an hour, with the full effects
clearly noticeable after about 2 hour.
4. How long will SUBOXONEFILMS/ BUNAVIL / ZUBSOLV last?
After the first hour, many people say they feel pretty good for most of the day. Responses to
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV will vary based on factors such as tolerance and
merablism.so each patient’s dosing is individualized. Your doctor may increase your does of
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV during the first week to help keep you from feeling sick.
5. Can I go to work right after my first does?
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV can cause drowsiness and slow reaction times. These
Reponses are more likely over the first few weeks of treatment, when your does is being is being
adjusted. During this time, your ability to drive, operate machinery, and play sports may be
affected. Some people do go to work right after their first SUBOXONEFILMS/ BUNAVIL /
ZUBSOLV machinery, dose; however, many people prefer to take the first and possibly the
second day off until they feel better. If you are concerned about missing work, talk with your
physician about possible way to minimize the possibility of your taking time off (e.g. Scheduling
your induction on a Friday).
6. Is it important to take my medication at the same time each day?
In order to make sure that you do not get sick, it is important to take you medication at the
same time each day.
7. If I have more than one tablet (film), do I need to take them together at the same time?
Yes and no- you do need to take your does at one “sittings, “But you do not necessarily need to
fit all the tablets under your tongue simultaneously. Some people prefer to take their tablets
this way because it faster, but this may not be what works best for you. The most important
things is to be sure to take the full daily does you were prescribed, so that your body maintains
constant levels of SUBOXONE.
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8. WHY DOES Suboxone films/ bunavil / zubsolv need to be placed under the tongue?
There are two large veins under your tongue (you can see them with a mirror). Placing the
medication under your tongue allows SUBOXNE to be absorbed quickly and safely though these
veins as the tablet dissolves. If you chew or swallow your medication, it will not correctly
absorbed as it is extensively metabolized by the liver. Similarly, if the medication is not allowed
to dissolve completely, you won’t receive the full effect,
9. Why can’t I talk while the medication is dissolving under the tongue?
When you talk, you move your tongue, which lets the undissolved SUBOXONEFILMS/ BUNAVIL /
ZUBSOLV “leak” out from underneath, thereby preventing it from being absorbed by the two
veins. Entertaining yourself by reading or watching television while your medication dissolves
can help the time to pass more quickly over 20-30 minutes after it dissolves.
10. Why does it sometimes only take 5 minutes for SUBOXONEFILMS/ BUNAVIL / ZUBSOLV to
dissolve and other times it takes much longer?
Generally, it takes 5-10 minutes for the tablets to dissolve. However, other factors (the moisture
of your mouth) can effect that times. Drinking something before taking your medication is a
good way to help the tablet dissolve more quickly.
11. If I forget to take my SUBOXONEFILMS/ BUNAVIL / ZUBSOLV for a day will I feel sick?
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV works best when taken every 24 hours; however, it may
last longer than 24 hours, so you may not get sick. If you miss your does, try to take it as soon as
possible, unless it is almost time for your next dose. If it is almost time for your next dose, just
skip the dose you forgot, and take next does as prescribed. Do not take two does at once unless
directed to do so by your physician.
On the future, the best way to help yourself remember to take your medication is to start taking
it the same time that your perform a routine, daily Activity, such as when you get dressed in the
morning .this way, the daily activity will start to serve as a reminder to take your SUBOXONE.
12. What happens if I still feel sick after taking SUBOXONEFILMS/ BUNAVIL / ZUBSOLV for a
while?
There are some reasons why you may still feel sick. You may not be talking the medication
correctly or the dose may not be right for you. It is important to tell you doctor or nurse if you
still feel sick.
13. What happens if I take drugs and then take SUBOXONE?
You will probably feel very sick and experience what is called a “precipitated withdrawal.”
Suboxone films/ bunavil / zubsolv competes with other opioids and will displace those
molecules form the receptors. Because SUBOXONEFILMS/ BUNAVIL / ZUBSOLV has less opioids
effects than full agonist opioids, you will go into withdrawal and feel sick.
14. What happens if I take Suboxone films/ bunavil / zubsolv and then take a drug?
As long as SUBOXONEFILMS/ BUNAVIL / ZUBSOLV is in your body, it will significantly reduce the
effects of any other opioids used, because SUBOXONEFILMS/ BUNAVIL / ZUBSOLV will dominate
the receptor sites and block other opioids from producing any effect.
15. What are the side effects of this medication?
Some of the most common side effects that patient experience are nausea, headache,
constipation ,and body aches and pains. However, most side effects seen with
SUBOXONEFILMS/ BUNAVIL / ZUBSOLV appear during the first week or two of treatment, and
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then generally subside. If you are experiencing any side effects, be sure to talk about it with your
doctor or nurse, as s/he can often treat those symptoms effectively until the abate on their own.
Patient Treatment Agreement
As a participant in medication treatment for opioid misuse and dependence freely and voluntarily agree
to accept this treatment agreement as follows:
1. I agree to keep, and be on time to, all my scheduled appointment (every 28 day).call and notify staff
of any changes in delay in appointment by talking to staff 24 hours min prior to appointment.
Otherwise a penalty of min. $50 for missed appointment or no show
Patient Initials
2. If unable to keep appointment set I agree to give a 24 hour notice and will have to be seen the next
day.
Patient Initials
3. I agree to adhere to the payment policy outline by this office.
Patient Initials
4. I agree to report my history and symptoms honestly to my doctor and the office staff will inform my
doctor about any medications (prescription and non-prescription) that I am taking. I will report any
changes in my medical history, such as becoming pregnant immediately.
Patient Initials
5. I agree not to sell, share, or give any of my medication to another person. I understand that such
mishandling of my medication is a serious violation of this agreement and would result in my
treatment being terminated without any recourse for appeal.
Patient Initials
6. I understand that my medication must be stored safely, where it cannot be taken accidentally by
children or pets, or stolen. If anyone else, including a child, takes my medication I will call 911 or
poison control at 1-800-222-1222 immediately and transfer to hospital.
Patient Initials
7. I agree not to deal drugs, steal, or conduct any illegal or disruptive activities in or around the doctor
office or ever.
Patient Initials
8. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or
suspected by employees of the pharmacy where my medication is filled, that the behavior will be
reported to my doctor’s office and could result in my treatment being terminated without any
recourse for appeal.
Patient Initials
9. I agree that my medication/prescription can only be given to me at my regular office visits. A missed
visit may result in my not being able to get my medication/prescription and may result in
termination of care from this office.
Patient Initials
10. I will be careful with my take-home prescription supplies of my medication, if I report that my
supplies have been lost or stolen my doctor may not provide me with a make-up supply. But that my
doctor has the right to not to.
Patient Initials
11. I understand that at every visit, my doctor will ask me to bring my unused and unused wrappers
/bottles supply of medication for a medication count and that I may not get refill if I do not bring my
medication with me.
Patient Initials
12. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place,
I agree that lost medication will not be replaced regardless of why it was lost.
Patient Initials
13. I agree not to obtain medication from any doctor, pharmacies, or other sources without telling my
treating physician.
Patient Initials
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14. I understand that mixing this medicine with other medication, especially benzodiazepines (for
example, Valium*, Klnopin+ or Xanax++) can be dangerous. I also recognize that several deaths
have occurred among person mixing buprenorphine and benzodiazepines (especially if taken
outside of a physician using routes of administration other than sublingual or in higher than
recommended therapeutic doses.)
Patient Initials
15. I agree to read the medication guide and consult my doctor should I have any questions or
experience any adverse events.
Patient Initials
16. I agree to take my medication as my doctor had instructed and not to alter the way I take my
medication without first consulting my doctor.
Patient Initials
17. I understand that medication alone is not sufficient treatment for my condition, and I agree to
participate in counseling as discussed and agreed upon with my doctor and specified in my
treatment plan.(AA,NA,CELEBRATE RECOVORY MEETINGS, SPONSORSHIP AAD CUUMAL USE
MENTAL HEALTH ADVISE )
Patient Initials
18. I agree to abstain from ALCOHOL, OPIOIDS, MARIJUANA, and COCAIN AND OTHER ADDITIVE
SUSBSTANCES (except nicotine.)
Patient Initials
19. I agree to provide random urine samples and have my doctor test my blood alcohol level.
20. I UNDERSTAND THAT VIOLATION OF THE ABOVE MAY BE GROUNDS FOR TERMINATION OF
TREATMENT.
Patient Initials
Patient Signature
Date
*Valium is a registered trademark of Roche products Inc.
+Klonopin is a registered trademark of Roche Laboratories Inc.
++ Xanax is a registered trademark of Pharmacia & UpJohn Company
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Quality Care Patient Intake
1. How long has the patient been using opioids?
M.D Notes:
List opioids or any other substance that the patient has missed, what quantity, what route and for how
long?
M.D Notes:
2. Does the patient have a history of substance abuse in his or her family?
No YES
Family member:
3. Has the patient ever been treated for substance misuse?
NO YES Where and When?
4. What is the patient experience with withdrawal?
5. What is the patients experience with relapse? How many times, where and why?
6. Comorbid medical or psychiatric conditions that may have contributed to opioid misuse?
7. List current prescription medication taken under a physician’s supervision and how often they are
taken?
8. Does the patient have a support network family, non-drug using friends, spouse, significant other,
etc.?
M.D NOTES:
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Clinical Opiate Withdrawal Scale
Resting Pulse Rate:
beats/minutes
(0) Pulse rate 80 or below
(1)Pulse rate 81-100
(2) Pulse rate 101-120
(4) Pulse rate greater than 120
Sweating: over past ½ hours not accounted for
by room temperature or patient activity
(0)No report of chills or flushing
(1)Subjective report of chills or flushing
(2) Flushing or observable moistness on face
(3) Beads of sweat on brow or face
(4) Sweat streaming off face
Restlessness: observation during assessment
(0) able to sit still
(1) Reports difficulty sitting still, but is able to do so
(3) Frequent shifting or extraneous movements of
legs/arms
(5) Unable to sit still for more than a few seconds
Pupil Size:
(0)pupils pinned or normal size for room light
(1)pupils possibly larger than normal for room
light
(2)pupils moderately dilated
(5)pupils so dilated that only the rim of the iris
is visible
Bone or Joint aches: if patient had pain
previously only the additional pain component
attributed to opiates withdrawal is scored
(0) not present
(1) mild diffuse discomfort
(2) Patient reports severe diffuse aching of
joint/muscles
(4) Patient is rubbing joints or muscles and is
unable to sit still because of discomfort
Running nose or tearing: not accounted for by
cold symptoms or allergies
(0) not present
(1) Nasal stuffiness or unusually moist eyes
(2) nose running or tearing
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(4) Nose constantly running or tears streaming
down cheeks
GI Upset: over last ½ hour
(0) no GI symptoms
(1) Stomach cramps
(2) nausea or loose stool
(3) vomiting diarrhea
(5) multiple episodes of diarrhea or vomiting
Tremor: observation of outstretched hands
(0) no tremor
(1) Tremor can be felt, but not observed
(2) Slight tremor observable
(4) gross tremor or muscle twitching
Yawning: observation during assessment
(0) no yawning
(1) Yawing once or twice during assessment
(2) Yawing three or more times during
assessment
(4) Yawning several times/minute
Anxiety or Irritability:
(0) none
(1) Patient reports increasing irritability or
anxiousness
(2) Patient obvious irritable or anxious
(4) Patient so irritable or anxious that
participation in the assessment is difficult
Gooseflesh Skin:
(0)Skin is smooth
(3) Piloerection of skin can be felt or hairs
standing up on arms
(5) Prominent pilerection
Total Score:
The total score is the sum of all 10 items
Score:
5-12= mild
13-24= moderate
25-36=moderately severe
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Goal for safe induction 25-36
More than 36= severe withdrawal
Reprinted with permission of the California society of Addiction
Medicine
PATIENT MEDICAL HISTORY
I.
Full legal name:
Current Address:
Home number
Cell phone
How did you hear about us?
Referring health care provider, if any
Date of birth
Age
Place of Birth
Marital Status
year’s marries/long-term relationship
Times married
Times divorced
Children Yes No current ages?
Residing with you? Yes No if no, where?
Do you have family nearby? Yes No
Education: check most recent degree
Graduate School
College
Professional or Vocational School
high school
Are you currently employed? Yes No
If yes where?
How long have you worked there?
Have you ever been arrested or convicted?
No
Yes
DWI DRUG-RELATED
DOMESTIC VIOLENCE
OTHER
Have you ever been abused? No
Physically
Sexually (including rape or attempted rape)
verbally
emotionally
Have you ever attended?
AA:
current
past NA:
current
past CA:
current
past
ACOA:
current
past OA:
current
past
If you are not currently attending meetings, what factors led you to stop?
Have you ever been in counseling or therapy
No Yes Where?
When?
What is your religious Preference?
Ethnic background?
II.
State in a few words why you wish a medical examination.
Do you have a physical handicap?
What kind of exercise do you do?
Have you used any street drugs?
Have you done any drug IV? No Yes When
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Grade
Do you have Hepatic C/B and or HIV? No Yes
Do you have a regular physician?
When did you last see a Physician?
When was your last eye exam?
Dental exam
Are the people living with you healthy? Yes No Do they do drugs or drink alcohol?
If not, what kind of disease do they have?
What is your present weight?
One year ago
Are you trying to lose weight Yes
No
During an average day:
How many times do you eat each day?
1. What do you have for breakfast?
2. What do you have for lunch?
3. What do you have for supper?
4. What do you have between meals?
5. How many cups of coffee / tea each day do you have?
6. How many soft drinks each day do you have?
III. Personal Profile:
Where do you live?
Rent
Own
living with someone homeless
How many people live with you?
Do you smoke?
Have you ever smoked?
How many cigars or pack of cigarettes each day?
Do you drink alcohol?
How much each day?
CAGE:
1. Have you ever felt you should cut down on your drinking?
Yes
No
2. Have people annoyed you by criticizing your drinking? Yes
No
3. Have you ever felt bod or guilty about your drinking? Yes
No
4. Have you ever had a drink first thing in the morning to steady your nerves or getting rid of a
hangover? Eye-opener?
Yes
No
Emergency contact:
Phone:
Relationship to patient
Primary care physician:
Phone:
Date of last physical:
Have you ever has an EKG?
Have you had blood/Laboratory work? No Yes When?
Date
Current or past medical conditions: (check all that apply)
( ) History of IV Drug use
( ) Cardiovascular (heart attack, high
( ) Asthma/Respiratory
cholesterol, angina)
( ) Hypertension
( ) Epilepsy or seizure disorder
( ) Head trauma
( ) HIV/AIDS
( ) Liver Problems hepatitis C/B
( ) Pancreatic
( ) STD
( ) Abnormal Pap smear
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( ) GI disease
( ) Diabetes
( ) Thyroid disease
( ) Nutritional deficiency
Other (Please describe):
If there a family history of any of the illnesses listed above, please N “F” next to that illness
MD NOTES:
Is there a family history of anything NOT listed here? (Please explain)
MD NOTES:
Have you ever had surgery or been hospitalized? (Please explain) Where, When, Why
MD NOTES:
Childhood illnesses
( ) Measles
( ) Mumps
( ) Chicken Pox
( ) Other:
Have you or a family member ever been diagnosed with a psychiatric or mental illness? (Please describe)
Have you ever taken or been prescribed antidepressants?
No
Yes If yes for what reason
Medication(s) and dates of use:
why stopped?
Please list all current prescription medications and how often
you take them (example: Dilantin 3x/day)
DO NOT include medication you may be currently missing (that information is needed later)
please list all current herbal medicines, vitamin supplements, etc. and how often you take them
MD NOTES:
Please list any allergies you have (penicillin, bees, peanuts)
Tobacco History
Cigarettes: Now
Yes
No In the past? Yes
No
How many per day on average?
For how many years?
Pipe: Now Yes
No In the past? Yes
No
How often per day on average?
For how many years?
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Have you ever been treated for substance misuse?
and for how long)
How long have you been using substances?
Dip tobacco, how many cans per day?
Substance Use History
No
Yes/Past
Yes /Now
Alcohol
Caffeine
(pills or beverages)
Cocaine
Crystal MethAmphetamine
Heroin
Inhalants
LSD or Hallucinogens
Marijuana
Methadone
Pain killers
PCP
Stimulants(pills)
Tranquilizers
/Sleeping pills
Ecstasy
Other:
Other:
Other:
Yes
Route
No (If yes please describe when, where
How
much
How
often
Did you ever stop using any of the above because of dependence?
Yes
Date/time of
last use
No (Please list)
What was your longest period of abstinence?
MD NOTES:
IV.
Infections :( if yes give approx. Age)
1. German measles (Rubella)
2. Red Measles
3. Chicken pox
4. Whooping Cough
5. Mumps
6. Rheumatic fever
Page 14 of 20
Patient Initials:
Yes
Yes
Yes
Yes
Yes
Yes
No Age
No Age
No Age
No Age
No Age
No Age
Date:
/
/
.
PROVIDER:
Quantity last
used
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Pneumonia
Typhoid fever
Malaria
Tuberculosis
Asthma
Hay fever
Jaundice(hepatitis)
Mononucleosis
Meningitis
Syphilis
Gonorrhea
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No Age
No Age
No Age
No Age
No Age
No Age
No Age
No Age
No Age
No Age
No Age
Medications:
Prescribed medication:
Medication you take without a prescription? (Such as aspirin, vitamins, laxatives, etc.)
Allergies :( including both foods and drugs and type of reactions)
Immunizations: (vaccinations against infection) year given or result
Tetanus (lockjaw)
Yes
No
Year
German measles
yes
No
Year
Pneumovax (pneumonia)
Yes
No
Year
Mumps
Yes
No
Year
TB Skin Test
Yes
No
Year
V. Review of systems:
A. Skin:
Have you had any significant infections or disease of the skin?
Has your skin changed in character or texture recently?
Are you bothered with severe itching?
Have you had a skin rash?
Has your hair changed in amount or texture?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
No
Not Sure
B. Head:
Do you suffer frequent headaches/migraines?
Do you have sick headaches?
Do you faint easily?
Have you ever been knocked unconscious?
Do you have light-headedness or giddiness?
Did you ever have dizziness?
C. Eyes:
Do you have eye trouble?
When?
Page 15 of 20
Patient Initials:
Date:
/
/
.
PROVIDER:
Do you wear glasses?
When started?
Did you ever see double?
Have you had any loss of vision?
Have you had inflammation of the eyes?
Yes
No
Not Sure
Yes
Yes
Yes
No
No
No
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Yes
No
Not Sure
Yes
Yes
No
No
Not Sure
Not Sure
Yes
No
Not Sure
Yes
No
Not Sure
Yes
No
Not Sure
Yes
No
Not Sure
Yes
No
Not Sure
Yes
Yes
No
No
Not Sure
Not Sure
D. Ears:
Have you had any loss of hearing?
Have you ever had earaches or discharge from your ears?
Do you have buzzing or ringing in your ears?
Have you ever had your ear drums punctured?
E. Nose:
Do you have frequent colds?
Do you have excessive nasal discharged?
Did you ever have frequent or sever nosebleeds?
Have you had sinus trouble?
F. Teeth:
Have you had excessive trouble with your teeth?
Do you gums bleed frequently?
Do you wear false teeth?
Is your tongue frequently sore or sensitive?
G. Throat:
Have you had frequent or severe sore throats?
Have you had sores in your mouth?
Do you have difficulty in swallowing?
Are you subject to hoarseness?
H. Neck:
Have you had swollen glands (lymph nodes) in your neck?
When?
Have you had a goiter?
Have you had a thyroid blood test or metabolism test done?
When?
Have you ever been treated for thyroid problem?
When?
Have you ever had any radiation treatment?
I. Breasts:
Have you noticed lumps or nodules in your breast?
When?
Have you had any discharged from your breast?
When?
Have you had an operation on your breast?
When?
Do you examine your own breast for tumors?
Have you ever had mammogram (breast x-ray)?
Page 16 of 20
Patient Initials:
Date:
/
/
.
PROVIDER:
If yes, date and results
J. Lungs:
Have you been told that you have any lung or bronchial trouble?
Do you have a chronic cough?
Do you raise more than one tablespoon of sputum daily?
Have you ever coughed up blood?
Have you had pleurisy?
When?
Have you noticed a wheeze or whistle in your chest on breathing?
Have you had close contact with a person who had tuberculosis?
Have you been exposed to severe dust or fumes for long periods?
When was your last x-ray of your chest?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
No
No
Not Sure
Not Sure
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
No
Not Sure
K. Heart:
Have you been told you have heart disease or heart murmurs?
Have you been told you had high blood pressure?
When?
Do you become winded on climbing two flight of stairs?
Do you have pain or a tightness feeling in your chest on exertion?
Do you have to sleep propped up in bed?
Do your ankles swell?
Do you have palpitations (heart beating rapidly)?
Have you been refused life insurance at normal rates?
Have you had an EKG (heart tracing)?
If yes, when
L. G.I.:
Have you noticed any loss of appetite?
Do any foods cause indigestion or diarrhea?
Do you have indigestion or excessive gas?
Have you ever had stomach, colon or gallbladder x-ray?
Do you have pain in your stomach?
Do you have nausea and vomiting?
Have you vomited blood?
When?
Are you constipated?
Have you bowel habits changed in the past 6 months?
Do you have attacks of diarrhea (frequent loss stools)?
Have you passed blood in you stools?
Have you had black or tarry stools?
When?
Do you pass mucus in your stools?
Page 17 of 20
Patient Initials:
Date:
/
/
.
PROVIDER:
Do you have hemorrhoids (piles)?
Have you been jaundiced (yellow eyes and skin)?
Have you had intestinal worms or parasites?
Yes
Yes
Yes
No
No
No
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
No
No
No
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
No
No
No
Not Sure
Not Sure
Not Sure
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
No
Not Sure
M. G.U:
Do you get up every night to urinate?
Do you have burning pain when you urinate?
Have you had pus in your kidneys or urine?
Do you have trouble starting your stream when you urinate?
Have you had a kidney or bladder stone?
Have you had albumin (protein) in the urine?
Have you passed blood in the urine?
When?
Do you ever lose control of your bladder?
Has a doctor ever said you had a kidney or bladder infection?
Have you had prostate infection?
Have you been told your kidneys are failing?
N. Neurologic, bones and joints:
Did you ever have painful or swollen joints?
Are you subject to rheumatism?
Have you ever had trouble with your back?
When?
Do you have varicose veins?
Have you ever had phlebitis (blood clots)?
Do you have pain in your legs or hips when walking or at night?
Was any part of your body ever paralyzed?
Do you have shooting pains in your arms or legs?
Do you have numbness or tingling (pins and needles) your fingers or toes?
Have you ever been told you have epilepsy?
Do you have dizziness or fainting?
Do you have tremors or shakes?
O. Emotions:
Are you tired when you get up in the morning?
Have you ever had a nervous breakdown?
Have you ever consulted a psychiatrist?
When?
Do you cry easily?
Do you worry very much?
Do you regard yourself as being nervous?
Do you tire easily?
Are you depressed and blue much of the time?
When did it start?
Is it difficult for you to make up your mind?
Page 18 of 20
Patient Initials:
Date:
/
/
.
PROVIDER:
Are your feelings easily hurt?
Are you easily irritated and upset?
Does every little thing get on your nervous?
Are you extremely shy or sensitive?
Do people often annoy or irritate you?
Do you consider your sexual life satisfactory?
Are there sever emotional stresses in your family?
Have you ever contemplated suicide?
When?
Are there emotional stresses in your job?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Yes
No
Not Sure
yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
Not Sure
P. Endocrine and hematology:
Have you ever had sugar in your urine
Are you excessively thirsty?
Is your energy level O.K.?
Has your voice changed recently?
Are you warm or cold when other are comfortable?
Do you have a history or anemia (low blood)?
Have you ever bleed excessively from dental work or a small cut?
Q. For Females Only:
Are you pregnant? No Yes
Are you still have regular periods? Yes
No if so, date of last periods?
How old where you when menstruation began?
During your periods do you/did you:
Have a pains that made you lie down?
Get tense or jumpy?
Have bleeding or discharge between periods?
Have irregular periods?
Swell before your periods?
If you had menopause (the change)?
Have you had any vaginal bleeding
Hot flashes?
Have you ever had an abnormal pap smear?
Date of last Pap smear
NORMAL
ABNORMAL
So you have a vaginal discharge now?
How many pregnancies have you had?
How many miscarriages or abortions did you have?
Are you using any birth control
What kind?
VI. Family History (state health or cause of death in each)
Father Age
Cause of death
Mother Age
Cause of death
Brother(s) Age
Cause of death
Page 19 of 20
Patient Initials:
Date:
/
Age at death
Age at death
Age at death
/
.
PROVIDER:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
Sister(s) Age
Cause of death
Age at death
Which of you close relatives have had any of the following: (this includes your immediate family,
grandparents, aunts or uncles)
Tuberculosis
Diabetes (sugar in urine)
Cancer
High blood pressure
Heart disease
Mental or emotional disorder
Thyroid disease of goiter
Bleeding tendency or anemia
Alcoholism
Kidney disease
Other family disease
VII. Activities of daily living
Bethel Index for Chronic Illness
1. Feeding (if food need to be cut up –with help)
With Help
Independent
2. Moving form care to bed and return (includes sitting up in bed)
With Help
Independent
3. Personal toilet (wash face, comb hair,shave,clean teeth)
With Help
Independent
4. Getting on and off toilet(handling clothes,wipe,flush)
With Help
Independent
5. Bathing
With Help
Independent
6. Walking on level surface(or if unable to walk, propel wheelchair)
With Help
Independent
7. Ascend and descend stairs
With Help
Independent
8. Dressing (includes trying on shoes, fastening fasteners)
With Help
Independent
9. Controlling bowels
With Help
Independent
10. Controlling bladder
With Help
Independent
Who provides the major portion of care for this individual? Self or other
Does the care taker need assistance? (If yes please describe)
Page 20 of 20
Patient Initials:
Date:
/
/
.
PROVIDER: