Dr. Gerald B Harris, II

Available Forms

Consent/Release Form Contract for Long-Term Controlled Substances Therapy for Chronic Pain and/or Dependence/Addiction Financial Policy Insurance Information New Patient - Registration New Patient - System Review Referral Form Weekly Blood Pressure Log Well-Woman Exam New Patient - Health History Questionnaire New patient - Alcohol Screening Test New patient - Depression Screening Pain Assessment New patient - Drug Abuse Screening Test (DAST) In House Drug Screen Results Therapy Progress Report Well Man Exam

Therapy Progress Report

Patient Name *

First and Last Name

Date *

Current Medication Dose

Pick the answer that best fits the way you feel right now. We are using a scale of 0 to 4 where "0" is for not at all and "4" is extremely. Please answer as honestly as possible as this helps us better address your needs.

I feel anxious *

I feel like yawning *

I am perspiring *

My nose is running and/or my eyes are watery *

I have goosebumps and/or chills *

I feel nauseated or like I may need to vomit *

I have stomach cramps and/or diarrhea *

My muscles twitch *

I feel dehydrated and/or have not have much appetite *

U am having difficulty sleeping *

I have a headache *

My muscles and bones ache *

I feel like using right now *

I would rate my overall withdrawl as *

Do you feel you need a dosage change

Yes

Down

Have you used alcohol or other drugs since your last visit? *

Yes

If "yes," please describe what, when , and how much

* Required field