Apex Health

Enter your name: * Date of Birth: *

The following questions all apply to the last 30 days:

1. How often have you had trouble with thinking clearly or had memory problems? * 2. How often do people complain that you are not completing necessary tasks? (including going to class, work, or appointments) * 3. How often have you had to go to someone other than your prescribing physician to get sufficient pain relief from medications? (eg another doctor, the ER, friends, or 'street' sources) * 4. How often have you taken your medications differently than they were prescribed? * 5. How often have you seriously thought about harming yourself? * 6. How much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)? * 7. How often have you been in an argument? * 8. How often have you had trouble controlling your anger? (eg. road rage, yelling, etc) * 9. How often have you needed to take pain medications belonging to someone else? * 10. How often have YOU been worried about how you're handling your medications? * 11. How often have OTHERS been worried about how you're handling your medications? * 12. How often have you had to make an emergency phone call or show up at a clinic without an appointment to get medicine? * 13. How often have you gotten angry with people? * 14. How often have you had to take more of your medication than prescribed? * 15. How often have you borrowed medication from someone else? * 16. How often have you used your pain medicine for symptoms other than for pain? (eg to help you sleep, improve your mood, or relieve stress)? * 17. How often have you had to visit the Emergency Room? * Use this field if you want to provide any additional information or explanation of above answers. Enter your name again to attest the above information is correct to the best of your knowledge. * Today's Date: *

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