please answer the questions choosing one selection only

HOW OFTEN DO YOU HAVE MOOD SWINGS? *
HOW OFTEN HAVE YOU FELT A NEED FOR HIGHER DOSES OF MEDICATION TO TREAT YOUR PAIN? *
HOW OFTEN HAVE YOU FELT IMPATIENT WITH YOUR DOCTORS? *
HOW OFTEN HAVE YOU FELT THAT THINGS ARE JUST TOO OVERWHELMING THAT YOU CAN'T HANDLE THEM? *
HOW OFTEN IS THERE TENSION IN THE HOME? *
HOW OFTEN HAVE YOU COUNTED PAIN PILLS TO SEE HOW MANY ARE REMAINING? *
HOW OFTEN HAVE YOU BEEN CONCERNED THAT PEOPLE WILL JUDGE YOU FOR TAKING PAIN MEDICATION?  *
HOW OFTEN DO YOU FEEL BORED? *
HOW OFTEN HAVE YOU TAKEN MORE PAIN MEDICATION THAN YOU WERE SUPPOSED TO? *
HOW OFTEN HAVE YOU WORRIED ABOUT BEING LEFT ALONE? *
HOW OFTEN HAVE YOU FELT A CRAVING FOR MEDICATION? *
HOW OFTEN HAVE OTHERS EXPRESSED CONCERN OVER YOUR USE OF MEDICATIONS? *
HOW OFTEN HAVE ANY OF YOUR CLOSE FRIENDS HAD A PROBLEM WITH ALCOHOL OR DRUGS? *
HOW OFTEN HAVE OTHERS TOLD YOU THAT YOU HAD A BAD TEMPER? *

PLEASE CONTINUE

HOW OFTEN HAVE YOU FELT CONSUMED BY THE NEED TO GET PAIN MEDICATION? *
HOW OFTEN HAVE YOU RUN OUT OF MEDICATION EARLY? *
HOW OFTEN HAVE OTHERS KEPT YOU FROM GETTING WHAT YOU DESERVE? *
HOW OFTEN, IN YOUR LIFETIME, HAVE YOU HAD LEGAL PROBLEMS OR BEEN ARRESTED? *
HOW OFTEN HAVE YOU ATTENDED AA OR NA MEETING? *
HOW OFTEN HAVE YOU BEEN IN AN ARGUMENT THAT WAS SO OUT OF CONTROL THAT SOMEONE GOT HURT? *
HOW OFTEN HAVE YOU BEEN SEXUALLY ABUSED? *
HOW OFTEN HAVE OTHERS SUGGESTED THAT YOU HAVE A DRUG OR ALCOHOL PROBLEM? *
HOW OFTEN HAVE YOU HAD TO BORROW PAIN MEDICATIONS FROM YOUR FAMILY OR FRIENDS? *
HOW OFTEN HAVE YOU BEEN TREATED FOR AN ALCOHOL OR DRUG PROBLEM? *

LETS FIND OUT

FAMILY HISTORY OF DRUG ABUSE *
PERSONAL HISTORY OF DRUG ABUSE *
AGE *
HISTORY OF PREADOLESCENT SEXUAL ABUSE *
PSYCHOLOGICAL DISEASE *

ALMOST COMPLETE WITH THIS SURVEY

HAVE YOU EVER FELT THAT YOU SHOULD CUT DOWN ON YOUR DRINKING *
HAVE PEOPLE ANNOYED YOU BY CRITICIZING YOUR DRINKING *
HAVE YOU EVER FELT BAD OR GUILTY ABOUT YOUR DRINKING *
HAVE YOU EVER HAD A DRINK FIRST THING IN THE MORNING TO STEADY YOUR NERVES OR TO GET RID OF A HANGOVER *

PART TWO

In the past 30 days how often have you had trouble with thinking clearly or had memory problems? *
In the past 30 days, how often DO people complain that you are not completing necessary task? (I.e., doing things that need to be done, such as going to class, work or appointments) *
In the past 30 days, however often had you had to go to someone other than you're prescribing physician to get sufficient pain relief from medications? (I.e., another doctor, emergency room, friends, Street sources) *
In the past 30 days, how often heavy taking your medications differently from how they are prescribed? *
In the past 30 days how often have you seriously thought about hurting yourself *
In the past 30 days how much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)? *
In the past 30 days, how often have you been in an argument? *
In the past 30 days, how often he had trouble controlling her anger (e.g., road rage, screaming, etc.)? *
In the past 30 days, however often had you needed to take pain medications belonging to someone else ? *
In the past 30 days, how often have you been worried about how you're handling your medications? *
In the past 30 days, how often have others been worried about how you're handling your medications? *
In the past 30 days, how often have you had to make an emergency phone call or show up at the clinic without an appointment? *
In the past 30 days, how often have you gotten angry with people? *
In the past 30 days, how often have you had to take more of your medication than prescribed? *
In the past 30 days, how often have you borrowed pain medication from someone else? *
In the past 30 days, how often have you use your pain medication for symptoms other than for pain (e.g., to help you sleep, improve your mood, or relieve stress)? *
In the past 30 days, how often heavy head to visit the emergency room? *
FROM 0 (NO PAIN) TO 10 (PAIN AS BAD AS YOU CAN IMAGINE) WHAT NUMBER BEST DESCRIBES YOUR PAIN WITHIN THE PAST WEEK *
WHAT NUMBER DESCRIBES HOW, WITHIN THE PAST WEEK, PAIN HAS INTERFERED WITH YOUR ENJOYMENT OF LIFE (0 IS DOES NOT INTERFERE AND 10 IS COMPLETELY INTERFERES) *
WHAT NUMBER BEST DESCRIBES HOW, DURING THE PAST WEEK, PAIN HOW INTERFERED WITH YOUR GENERAL ACTIVITY (0- DOES NOT INTERFERE AND 10- COMPLETELY INTERFERES) *
BY CHECKING  THE BOX, I HEREBY AUTHENTICATE  AND ACKNOWLEDGE AS TRUE, THAT  THIS  MEDICAL FORM IS  CORRECT, HAS BEEN REVEIWED BY ME, THE CLIENT,  AND  IS AN ACCEPTABLE  REPRESENTATION OF  MY CURRENT    APPLICABLE  HEALTH  STATUS *
Signature authenticating all above here please *
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thank you  for  your  responses   tf medical "lives serving lives"