OPIOID CLINIC - INTAKE FORMThank you for considering our clinic for your chronic pain management needs. To ensure your safety and provide you with the best possible care, we've developed a brief screening questionnaire. This questionnaire aims to gather essential information about your opioid usage and history. Your honest and accurate responses will help us tailor our services to meet your individual needs effectively. Please answer the questions to the best of your ability. Be assured that all information you provide will be treated with the utmost confidentiality and used solely for the purpose of optimizing your plan of care. If you have any concerns or require assistance while completing the questionnaire, our staff members are here to help you. Your well-being is our top priority, and we're committed to supporting you on your healing journey toward recovery and improved health. Thank you for entrusting us with your care and welcome to Solutions In Pain.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Email *What is your name ? *FirstLastAre you currently prescribed or have been prescribed opioid medication(s) ? *Currently prescribedPrescribed in the pastNever prescribed currently or in the pastWhat opioid medication(s) are you currently or have used in the past ? *Hydrocodone-Acetaminophen (i.e Tylenol #3)OxycodoneOxymorphoneHydrocodoneHydromorphoneFentanylMorphineCodeineMethadoneTramadolBuprenorphineOtherWhat is the dose (mg or mL) of your opioid medication(s) ? *Please list the dose strength of all your opioid medication(s) below. *How many times a day and/or week do you take your opioid medication(s) ? *What medical condition(s) were you prescribed opioid medication(s) for ? *Have you ever heard of the term "opioid mitigation" ? *YesNoHave you ever tried to limit or quit your use of opioid medication(s) ? *YesNoIf the answer was yes to the prior question. What happened ? If the answer was no to the prior question. Please respond with "N.A" *Are you ready to begin coming off your opioid medication(s) ?Not at allTo a slight degreeTo a moderate degreeTo a great degreeEffective immediatelyWhat is your ideal timeline for coming off your opioid medication(s) ? *Please Upload a picture of the back and front of your Insurance card and ID card * Click or drag files to this area to upload. You can upload up to 5 files. Submit
