"Buprenorphine Treatment Intake History and Physical Form - Pcss"

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Buprenorphine Treatment
Intake History and Physical
NAME:
DATE:
Chief Complaint:
Opiate use history:
Yrs/mos of use
Route of Admin
Current length of continuous use
Amount of current use
Last use date/time
Present Symptoms
History of drug abuse treatment:
Medical History:
Allergies:
Current med:
Medical/psychiatric problems:
Hospitalization/surgery:
Psychiatric treatment:
Hepatitis
SBE______
HIV_______
TB_______
STD________
(women) LMP______
G____ P____ TAB____ SAB ____ Contraception________________________
ROS:
Other Drug Abuse History:
Cocaine/stimulant:_________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical/Psychiatric Complications of Use:
Alcohol: Current amount:____________________________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical/Psychiatric Complications of Use:
Benzodiazepines:__________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical Complications of Use:
Marijuana:__________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Medical Psychiatric
Complications of Use:
Caffeine: Current Use:__________ Mos/Yrs of Use:_____
Nicotine/cigaretts:__________ Pack years:__________
Nutrition History:
Routine screening history (pap, chol, TB, Hep Panel, HIV, ECG, Pregnancy test, etc.):
400 Massasoit Ave. Suite 307, 2nd Flr. | East Providence RI 02914| P: (888) 572-7724 F: (401) 272-0922 | Email: pcssmat@aaap.org
pcssmat.org |Twitter: @PCSSProjects
Buprenorphine Treatment
Intake History and Physical
NAME:
DATE:
Chief Complaint:
Opiate use history:
Yrs/mos of use
Route of Admin
Current length of continuous use
Amount of current use
Last use date/time
Present Symptoms
History of drug abuse treatment:
Medical History:
Allergies:
Current med:
Medical/psychiatric problems:
Hospitalization/surgery:
Psychiatric treatment:
Hepatitis
SBE______
HIV_______
TB_______
STD________
(women) LMP______
G____ P____ TAB____ SAB ____ Contraception________________________
ROS:
Other Drug Abuse History:
Cocaine/stimulant:_________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical/Psychiatric Complications of Use:
Alcohol: Current amount:____________________________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical/Psychiatric Complications of Use:
Benzodiazepines:__________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Route:____
Medical Complications of Use:
Marijuana:__________ Current amount:__________ Mos/Yrs of Use:_____ Last Use_____ Medical Psychiatric
Complications of Use:
Caffeine: Current Use:__________ Mos/Yrs of Use:_____
Nicotine/cigaretts:__________ Pack years:__________
Nutrition History:
Routine screening history (pap, chol, TB, Hep Panel, HIV, ECG, Pregnancy test, etc.):
400 Massasoit Ave. Suite 307, 2nd Flr. | East Providence RI 02914| P: (888) 572-7724 F: (401) 272-0922 | Email: pcssmat@aaap.org
pcssmat.org |Twitter: @PCSSProjects
Physical Examination:
T_____ P_____ BP_____ R_____ WT_____ HT_____ Gen. Appearance:
HEENT:
ABD
Thyroid/neck
Back
Heart
Neuro
Lungs
Extrem
Chest/breast
Skin
Tracks/scars
Patient Name:
Signs of Opioid Withdrawal:
Date/Time of Last Use:
Pupils
Rhinorrhea
Lacrimation
Perspiration
Pilorection
Increase Temp.
Increase BP
Tachycardia
Vomiting
Diarrhea
Myalgia/Joint Pain
Anxiety
COWS score
Screening Laboratory Results:
Urine Drug Screen Results:
Liver Function Test Results:
Other Labs (CBC, chemistries):
Office-based opioid dependence treatment assessment:
Opioid Dependence
Yes_____
No_____
_____ withdrawal: Degree: None
Minimal
Moderate
Severe
Other Diagnoses:
400 Massasoit Ave. Suite 307, 2nd Flr. | East Providence RI 02914| P: (888) 572-7724 F: (401) 272-0922 | Email: pcssmat@aaap.org
pcssmat.org |Twitter: @PCSSProjects
Initial Treatment Plan:
Screening for Appropriateness for Buprenorphine Treatment
____ Laboratory testing: CBS, Chem Panel (ALT, AST, GGTP Tot Bili, Alk Phos, Glc, BUN Creatinine,
Chol/Trig), Urine Drug Screen (expaned panel for opioids)
Other:_____ Hepatitis Panel_____ HIV Antibody_____ Pregnancy Test (Urine/Serum)_____ ECG_____
____ TB test: placed date__________ to be read date__________
Initial Orders
____ admit to Buprenorphine maintenance/medical withdrawal treatment
Induction dose orders:
____ urine drug screen schedule
Counseling plans:
Next visit:
Maintenance Buprenorphine/Naloxone Dose:
Signed:
Date:
400 Massasoit Ave. Suite 307, 2nd Flr. | East Providence RI 02914| P: (888) 572-7724 F: (401) 272-0922 | Email: pcssmat@aaap.org
pcssmat.org |Twitter: @PCSSProjects
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