Apex Health

Opioid Dependence Survey - Fill out WITHIN ONE DAY of your appointment!

Enter your name: *

Date of birth: *

Today's Date: *

I feel anxious *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

I feel like yawning *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

I am perspiring/sweating *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

Runny nose / watery eyes *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

Goose bumps / chills *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

Nauseated or vomiting *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

Stomach Cramps / Diarrhea *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

My muscles twitch *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

Feel dehyrated or don't have an appetite *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

Having difficulty sleeping *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

I have a headache *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

My muscles or bones ache *

0 - not at all

1 - mildly

2 - moderately

3 - severely

4 - extremely

I feel like using drugs right now *

0 - not at all

1 - maybe a little bit

2 - moderately yes

3 - most likely yes

4 - absolutely if I could

I would rate my overall level of withdrawal today as: *

0 - not at all

1 - mild

2 - moderate

3 - severe

4 - extreme

Do you feel you need a dosage change? *

Yes - DOWN

Yes - UP

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

Yes

If you answered yes above, please describe what, when, and how much

Please describe any problems or situations you found most stressful during the past week. If none, enter 'none' *

Medication and Treatment Information

Which medicine are you currently taking? I *

Suboxone Film (brand or generic)

Suboxone tablet (buprenorphine/naloxone)

Zubsolv tablet

Bunavail film

Injectable buprenorphine (Sublocade)

Buprenorphine tablet (Subutex)

NONE OF THE ABOVE

Enter the dose of your tablet or film *

8mg or 8/2 mg or 5.7 mg/1.4 tablet OR film

2 mg or 2/0.5 mg or 1.4/0.36 tab or film

4 / 1 mg film

12 / 3 mg film

check here if on injectable buprenorphine

check here if on a dose not listed above

check here if not on any buprenorphine products

Enter how you take your medicine throughout the day *

For example: "1 in AM, 1/2 pill at noon, 1/2 pill in PM". Do not answer "under my tongue". Do not enter how it is prescribed. Enter how YOU take it.

How many do you have left right now? *

Is this less than you should have? *

Yes

List any other controlled substances you are prescribed. If none, enter none. *

eg. clonazepam, alprazolam, Adderall, Ambien, etc.

Are you attending counseling? If yes, where and how often? *

What pharmacy do you use? Please include location, such as "CVS on Ellerbe" *

List any new medications you have started since last appointment

What concerns, if any, do you have about your treatment?

Enter your name again to attest that the above information is correct to the best of your knowledge: *

Available Forms

7. FOLLOW UP Opioid Dependence Progress Report

Opioid Dependence Survey - Fill out WITHIN ONE DAY of your appointment!

Medication and Treatment Information