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Day of Month12345678910111213141516171819202122232425262728293031
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Day of WeekT
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Email Address
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Patient's (your?) First Name
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Patient's (your?) Middle Name
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Patient's (your) Last Name
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Date of Completion of this form
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Anxiety Avg#DIV/0!
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Pain Avg#DIV/0!
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Depression/Mood Score0
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Rate your level of Anxiety at present (1-No Anxiety to 10-Very Intense Anxiety)#DIV/0!
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Generally, how much does your Anxiety problem interfere with your Day-To-Day Activities? (1-No Interference to 10-Extreme Interference)#DIV/0!
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Since the time you developed your Anxiety problem how much has your Anxiety changed your Ability to Work? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety changed the amount of Satisfaction or Enjoyment you get from Participating in Social and Recreational Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety changed your Ability to Participate in Recreational and other Social Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety changed the amount of Satisfaction you get from Family Related Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety affected your overall Mood? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety affected your overall Sleep? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety affected your Ability to do Household Chores? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety changed the amount of Satisfaction or Enjoyment you get from Work? (1-No Change to 10-Extreme Change)#DIV/0!
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How well controlled is your anxiety? (1-No Control, 10-Extreme Control)#DIV/0!
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Rate your level of Pain at present (1-No Pain to 10-Very Intense Pain)#DIV/0!
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Generally, how much does your pain problem interfere with your Day-To-Day Activities? (1-No Interference to 10-Extreme Interference)#DIV/0!
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Since the time you developed a pain problem, how much has your pain changed your Ability To Work (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain changed the Amount of Satisfaction or Enjoyment you get from participating in social and recreational activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain changed your Ability to Participate in recreational and social activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain changed the Amount of Satisfaction you get from family related activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain affected your overall Mood? (1-No Affect to 10-Extreme Affect)#DIV/0!
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How much has your pain affected your overall Sleep? (1-No Affect to 10-Extreme Affect)#DIV/0!
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How much has your pain affected your Ability to do Household Chores? (1-No Affect to 10-Extreme Affect)#DIV/0!
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How much has your pain changed the Amount of Satisfaction or Enjoyment you get from Work? (1-No Change to 10-Extreme Change)#DIV/0!
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How well controlled is your pain (1-No Control, 10-Extreme Control)#DIV/0!
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Little or no interest in doing things (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?0
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Feeling down, depressed, or hopeless (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?0
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Feeling tired or having little energy (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?0
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Poor appetite or over-eating (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?0
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 Feeling bad about yourself — or that you are a failure or have let yourself or your family down (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?0
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Trouble concentrating on things, such as reading the newspaper or watching television (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?0
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Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?0
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If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?0
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Addiction Interval History for the last 30 days or since your last visit;
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Date of last 12-Step meeting attended12/30/1899
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Number of 12-Step meetings attended per week0
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Date that you last spoke to your sponsor12/30/1899
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Highest step completed recently0
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Date of completion of highest step12/30/1899
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How satisfied are you with progress toward achieving your recovery goals? (1-Not at all, 10-Very#DIV/0!
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Are your medications kept secure (lock-box, away from children)
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Do you have enough income (from legal sources) to pay for necessities such as housing, transportation, food & clothing for yourself and your dependents?
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Does your religion or spirituality help support your recovery (1=very little, 10=very much)?#DIV/0!
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Do you think you might harm yourself or somebody else?
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If you answered "Yes" or "Maybe" about harm, please explain
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In the past 30 days, how would you describe your health
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In the past 30 days, how many of those days have you been bothered by arguments or problems getting along with any family members or friends?0
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In the past 30 days, how many nights did you have trouble falling asleep or staying asleep?0
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In the past 30 days, how many days have you felt depressed, anxious, angry or very upset throughout most of the day0
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In the past 30 days, how many days were you bothered by cravings or urges to drink alcohol or use drugs0
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In the past 30 days, how many days did you abuse other drugs not prescribed specifically to you by a licensed medical provider (steroids, non-prescription sleep pills/diet pills, Benadryl, Ephedra, other over-the-counter (OTC)/unknown medications0
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In the past 30 days, how many days did you attend any type of self-help meetings (like NA or AA) to help your recovery?0
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In the past 30 days, How many days were you in contact with or spent time with any family members or friends who are supportive of your recovery0
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In the past 30 days, how many days were you in any situations or with any people that put you at an increased risk for using alcohol or drugs (i.e., around "risky" people, places or things)0
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What is your longest clean period from any form of alcohol or other substances (approximate number of days)0
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How confident are you in your ability to NOT use alcohol and drugs in the next 30 days? (1 not at all confident-10 very confident)0
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In the past 30 days, how many days did you drink ANY alcohol0
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In the past 30 days, how many days did you have at least 5 drinks (if you're a man) or at least 4 drinks (if you are a woman)? (One "drink" is considered to be one (1) shot of hard liquor, 12 oz can/bottle of beer or 5 oz glass of wine)0
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If "Yes" in last 30 days or since we last saw you, how many days since last use of Alcohol?0
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If "Yes" in last 30 days or since we last saw you, how many days since last use of Pot?0
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In the past 30 days, how many days did you use any marijuana/pot/weed...0
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In the past 30 days, how many days did you illegally abuse any other stimulants (Eg. amphetamine, methamphetamine, Dexedrine, Ritalin, Adderall, "speed", "crystal meth", "ice", "uppers", etc.0
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How many days has it been since your last use of Amphetamines (uppers)?0
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In the last 30 days or since we last saw you, how many days have you used methamphetamine?0
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If "Yes" in last 30 days or since we last saw you, how many days since last use of Methamphetamine (crystal meth)?0
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In the past 30 days, how many days did you use any cocaine or crack?0
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How many days has it been since your last use of Cocaine or Crack?0
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In the past 30 days, how many days did you use any sedative/tranquilizers ( Eg. "Benzo's", Valium, Xanax/Xanabar, Ativan, Klonopin, Ambien, "Barbs" phenobarbital, other "downers"0
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How many days has it been since you've used any sedative/tranquilizers (Example: "Benzo's", Valium, Xanax/Xanabar, Ativan, Klonopin, Ambien, "Barbs" phenobarbital, other "downers")0
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In the past 30 days, how many days did you abuse ANY opiates (Eg. Heroin, Morphine, Dilaudid, Demerol, Oxycontin, Opana, Oxy, Tylenol 2,3,4, Percocet, Vicodin, Fentanyl, etc.)0
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If "Yes" in last 30 days or since we last saw you, how many days since you last swallowed any opiates?0
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If "Yes" in the last 30 days or since we last saw you, how many days since you last snorted opiates?0
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If "Yes" in last 30 days or since we last saw you, how many days since you last injected Opiates?0
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If "Yes" in last 30 days or since we last saw you, how many days since you last snorted Heroin?0
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If "Yes" in last 30 days or since we last saw you, how many days since you last injected Heroin?0
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If "Yes" in last 30 days or since we last saw you, how many days since last use of Methadone?0
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What was your daily dose of Methadone?0.00
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How many days has it been since your last use of hallucinogens/psychedelics?0
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In the past 30 days, how many days did you use any inhalants (glues/adhesives, nail polish remover, pain thinner, gasoline, etc.)0
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How many days has it been since your last use of an inhalant?0
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Do you have any concerns, problems, questions about, possible side effects from your medications?
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Do you have any concerns, problems, questions about your recovery that you wish to address with your provider today?
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Would you like to have acupuncture (Acudetox) today to help with your recovery today, and if so for how many minutes?
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Allergies/Adverse Reactions/Problem Medications:
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Please list ANY & EVERY medication or other substance that you have been exposed to SINCE YOUR LAST VISIT that either caused a problem (allergic reaction [describe reaction caused], adverse drug react]ion [describe reaction caused], medication that was ineffective [and the dose that was ineffective--some drugs won't work if the dose is just to low]) ("0"=None/NA)
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Medication Update:
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Current Medications used (Please list any NEW (since last visit) medication name, dose (mg), times per day/week/month taken, route of administration including inhalers, drops, skin creams, etc.) for any and all medications CURRENTLY used including changes by any other health care provider since your last visit ("0"=None/NA)