Apex Health - Publicforms

Available Forms

1. NEW PATIENT REGISTRATION FORM 2. NEW PATIENT Medical History 3. HIPAA Release and CONTACT Policy 4. CONTROLLED SUBSTANCE AGREEMENT 5. NEW PATIENT Opioid Dependence Scale 6. Clinic Rules Form 7. FOLLOW UP Opioid Dependence Progress Report

2. NEW PATIENT Medical History

Enter your Full Name: *

Date of Birth: *

Reason for visit *

Please enter as much information as you can about your opioid dependence history

When did you start taking pain pills, and why? *

If you are currently on some type of buprenorphine, prescribed or not, what are you taking, how much per day, and for how long? *

If not on buprenorphine, enter "NA"

If you have been prescribed buprenorphine meds previously, list the dates and doctor or clinic name *

If never prescribed, enter "NA"

What are your goals of treatment? *

There are no wrong answers

Any other issues to address at Apex Health?

Use this box for extra space if necessary, or if you have other issues to address.

Do you use any marijuana products? *

Are you taking any of the following? *

Are you using or previously used: *

Heroin

Fentanyl

Cocaine

Methamphetamine

PCP

Other illicit drugs not listed

None of the above

List any inpatient treatment for addiction including location and dates *

If none, enter "NA"

Drug Counseling? *

List detalis in the box below

If currently in Counseling, list location and name here:

NA/AA meetings? *

Any drug-related arrests? If yes, explain below *

explain in the box below

Any history of Court-ordered treatment? If yes, explain below *

Use this box to explain any above answers or for additional information *

If none, enter "NA"

Medical History

Who is your Primary Care Provider: *

List any other doctors you see and why:

Past Medical History *

If no medical history, enter "none"

Past Surgical History *

Please list approximate dates, surgeon, and place of surgery next to each surgery

List any hospitalizations or major illnesses not included above. Include month/year.

Is there any possibility you could be pregnant? *

Allergies

Check if you have: *

No known drug allergies

Penicillin

Sulfa

Statins

NSAIDS such as ibuprofen, Advil, naproxen, Aleve

If you have had intolerable reaction to Suboxone, please explain what happened here and how long you tried it: *

If you tolerate Suboxone or haven't tried it, enter "NA". "Bad taste" is not acceptable to insurance

List any other drug allergies

Medications

Please list all current medications, including dose and frequency. *

include all prescription and over the counter meds. If none, enter NA

Habits

Are you a current or former smoker? *

If you answered Yes above, how long have you have smoked and how many per day? If you have quit, how long ago?

Do you drink alcohol now or have you been a heavy drinker in the past? *

If you answered Yes above, how much do you drink and how often?

Any other drug use not previously mentioned? *

If yes, enter details in box below

Use this field if you want to elaborate on anything in the Habits section

Have you ever used drugs intravenously or by inhaling/snorting? *

Social History

Marital Status *

Are you sexually active? *

Never

With spouse/significant other only

With Males

With Females

Who do you live with? *

For example, 'mother', 'wife and 2 sons', 'partner'. No names please, unless they are also patients here.

Do you have children? *

If you have children, please list ages and whether or not they live with you.

What is your current occupation or usual line of work? *

If none, enter "currently unemployed, " "homemaker", or "disabled" if appropriate

Are you currently on Disability? *

If you answered YES above, what is the Disablity?

Family History - list any known medical problems

Alcohol / Drug Addiction in any family members? *

If YES above, what relation and what substance?

eg. 'Mothers brother - alcohol. Sister - opioids'

Father *

Enter 'NA' if alive and healthy

Mother *

Enter 'NA' if alive and healthy

Brothers/Sisters *

Enter 'NA' if alive and healthy

Grandparents *

Enter 'NA' if alive and healthy

Use this box if you have additional family history to report

PLEASE ENTER YOUR NAME AND DATE BELOW TO ATTEST THE ABOVE INFORMATION IS CORRECT TO THE BEST OF YOUR KNOWLEDGE

Name: *

Today's Date: *

* Required field