PainPA, LLC

Over the last 4 weeks, have you or how often have you been bothered by any of the following problems?

Any Emergency Room or Doctor visits? * craving for narcotics, alcohol or other drugs? (Copy) * Feeling down, depressed, or hopeless * Trouble falling or staying asleep, or sleeping too much * Feeling tired or having little energy * Poor appetite or overeating * Things that may have or led up to any use (triggers, situations, people) * Trouble concentrating on things, such as reading the newspaper or watching television * 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 * Thoughts that you would be better off dead, or of hurting yourself * Any withdrawal symptoms, especially late in the day or before your next dose? * Do you feel your current dose is holding you for the full interval? * How are work, school, or finances going? * If you have 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? (Copy)