PainPA, LLC

DRUG USE HISTORY

NOTE: this form is required for patients seeking detox or medially assisted treatment of opioids

PATIENT NAME * When and How did you start misusing drugs? * What are you currently using at this time? * Dosage (quantity) and frequency for any checked drugs * Do you have a history of any other addictive behaviors? * If yes, please check If other please describe

INTAKE SCREENER

Methadone and Suboxone History

Are you currently on Methadone Maintenance? * If yes, What is your dose? Have you ever been prescribed Suboxone before? * If yes, when were you on Suboxone? If yes, what was your dose? Why did you stop taking the Suboxone? Are you still on Suboxone? * Have you ever tried Suboxone without having a prescription? *

MENTAL HEALTH HISTORY

Have you ever been diagnosed with any mental health condition: * If yes, please specify: Have you ever been diagnosed with: * If other, please explain: REHAB HOSPITAL ADMISSIONS * Please list any medications. *

WARNING: YOU MUST CLICK "SUBMIT FORM" AND SEE A MESSAGE IN GREEN STATING "SUCCESSFULLY SUBMITTED" BEFORE GOING TO THE NEXT FORM OR THE ENTIRE FORM WILL BE LOST