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Health Problems |
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Pregnant | |
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If pregnant, are you seeking prenatal care? |
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Are you currently taking any medication? |
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Medication |
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Do you practice any complementary health approaches? |
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Do you have any allergies? |
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List Allergies, if any. | |
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Do you practice safe sex? | |
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Do you have a Primary Care Physician (PCP)? |
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If yes, who is your Primary Care Physician? | |
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Primary Care Physician Phone: | |
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Do you currently have any upcoming Dr appointments? |
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Do you currently have mental health services in place? |
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Is there a family history of mental illness and/or suicide? |
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If yes, explain |
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Are you aware of any other medical issues that need attention? |
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If yes, explain |
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Is there a family history of health concerns? |
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If yes, explain |
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Substance Use
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IV drug use in the last 30 days? (If "YES", one of the substances HAS to be an IV drug |
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Are you currently attending 12 step meeting (AA/NA etc)? | |
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Number of days attended AA/NA in last 30 days | |
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On a scale of 1 to 5, with 1 = no problem and 5 = severe problem, how would you rate your alcohol/drug use? | |
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Have you had any attempts to quit or reduce drinking or using? | |
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Have you had any periods of complete abstinence? | |
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If yes, reason/length of time? | |
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Does Client Currently Use Tobacco | |
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Daily Frequency of Cigarette Use | |
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What substances are you currently using, how much, and how used? What substances have you used in the past and include how long ago and how much used and how used? |
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Prior Treatment History in Last 10 years When, where, level, length, completed, length of abstinence |
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Where is most of your use done? | |
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In the past 12 months, how many times have you driven under the influence? | |
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What is the total number of arrests in the last 12 months? | |
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How many OWI's have you had in the Last 12 Months? | |
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How many arrests were related to non-drug or alcohol related crime while under the influence in the last 12 months? | |
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How many arrests were related to non-drug or alcohol related crime while not under the influence in the last 12 months | |
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How many arrests were related to drug or alcohol related crime in the last 12 months | |
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How many arrests have occurred in past 30 days? | |
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Are you interested in medication assisted treatment? (Examples include; Suboxone, Buprenorphine, Naloxone, Methadone, Anabuse) | |
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If you are interested in medication assisted treatment, why and what are you interested in? |
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Form Updates |
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Date |
Action |
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Form Started
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