subject_line
please answer the questions choosing one selection only
LAST NAME
*
MIDDLE INITIAL(S)
FIRST NAME
*
BIRTH (YEAR ONLY- EXAMPLE: 1967)
*
DATE FORM IS BEING COMPLETED
*
CLINIC FOR THIS VISIT LOCATION
*
HOW OFTEN DO YOU HAVE MOOD SWINGS?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU FELT A NEED FOR HIGHER DOSES OF MEDICATION TO TREAT YOUR PAIN?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU FELT IMPATIENT WITH YOUR DOCTORS?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU FELT THAT THINGS ARE JUST TOO OVERWHELMING THAT YOU CAN'T HANDLE THEM?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN IS THERE TENSION IN THE HOME?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU COUNTED PAIN PILLS TO SEE HOW MANY ARE REMAINING?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU BEEN CONCERNED THAT PEOPLE WILL JUDGE YOU FOR TAKING PAIN MEDICATION?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN DO YOU FEEL BORED?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU TAKEN MORE PAIN MEDICATION THAN YOU WERE SUPPOSED TO?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU WORRIED ABOUT BEING LEFT ALONE?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU FELT A CRAVING FOR MEDICATION?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE OTHERS EXPRESSED CONCERN OVER YOUR USE OF MEDICATIONS?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE ANY OF YOUR CLOSE FRIENDS HAD A PROBLEM WITH ALCOHOL OR DRUGS?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE OTHERS TOLD YOU THAT YOU HAD A BAD TEMPER?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
PLEASE CONTINUE
HOW OFTEN HAVE YOU FELT CONSUMED BY THE NEED TO GET PAIN MEDICATION?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU RUN OUT OF MEDICATION EARLY?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE OTHERS KEPT YOU FROM GETTING WHAT YOU DESERVE?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN, IN YOUR LIFETIME, HAVE YOU HAD LEGAL PROBLEMS OR BEEN ARRESTED?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU ATTENDED AA OR NA MEETING?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU BEEN IN AN ARGUMENT THAT WAS SO OUT OF CONTROL THAT SOMEONE GOT HURT?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU BEEN SEXUALLY ABUSED?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE OTHERS SUGGESTED THAT YOU HAVE A DRUG OR ALCOHOL PROBLEM?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU HAD TO BORROW PAIN MEDICATIONS FROM YOUR FAMILY OR FRIENDS?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
HOW OFTEN HAVE YOU BEEN TREATED FOR AN ALCOHOL OR DRUG PROBLEM?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
LETS FIND OUT
FAMILY HISTORY OF DRUG ABUSE
*
ALCOHOL
ILLEGAL DRUGS
PRESCRIPTION DRUGS
NONE
PERSONAL HISTORY OF DRUG ABUSE
*
ALCOHOL
ILLEGAL DRUGS
PRESCRIPTION DRUGS
NONE
AGE
*
IF YOU ARE BETWEEN 16 AND 45 CHECK THE BOX PLEASE
NOT IN THIS AGE RANGE
HISTORY OF PREADOLESCENT SEXUAL ABUSE
*
CHECK HERE IF THIS APPLIES TO YOU
DOES NOT APPLY TO ME
PSYCHOLOGICAL DISEASE
*
ATTENTION DEFICIT DISORDER
OBSESSIVE COMPULSIVE DISORDER
BIPOLAR
SCHIZOPHRENIA
DEPRESSION
NONE
ALMOST COMPLETE WITH THIS SURVEY
HAVE YOU EVER FELT THAT YOU SHOULD CUT DOWN ON YOUR DRINKING
*
NO
YES
HAVE PEOPLE ANNOYED YOU BY CRITICIZING YOUR DRINKING
*
NO
YES
HAVE YOU EVER FELT BAD OR GUILTY ABOUT YOUR DRINKING
*
NO
YES
HAVE YOU EVER HAD A DRINK FIRST THING IN THE MORNING TO STEADY YOUR NERVES OR TO GET RID OF A HANGOVER
*
NO
YES
PART TWO
In the past 30 days how often have you had trouble with thinking clearly or had memory problems?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
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)
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
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)
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often heavy taking your medications differently from how they are prescribed?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days how often have you seriously thought about hurting yourself
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days how much of your time was spent thinking about opioid medications (having enough, taking them, dosing schedule, etc.)?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often have you been in an argument?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often he had trouble controlling her anger (e.g., road rage, screaming, etc.)?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, however often had you needed to take pain medications belonging to someone else ?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often have you been worried about how you're handling your medications?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often have others been worried about how you're handling your medications?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
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?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often have you gotten angry with people?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often have you had to take more of your medication than prescribed?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often have you borrowed pain medication from someone else?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
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)?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
In the past 30 days, how often heavy head to visit the emergency room?
*
NEVER
SELDOM
SOMETIMES
OFTEN
VERY OFTEN
FROM 0 (NO PAIN) TO 10 (PAIN AS BAD AS YOU CAN IMAGINE) WHAT NUMBER BEST DESCRIBES YOUR PAIN WITHIN THE PAST WEEK
*
0
1
2
3
4
5
6
7
8
9
10
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)
*
0
1
2
3
4
5
6
7
8
9
10
WHAT NUMBER BEST DESCRIBES HOW, DURING THE PAST WEEK, PAIN HOW INTERFERED WITH YOUR GENERAL ACTIVITY (0- DOES NOT INTERFERE AND 10- COMPLETELY INTERFERES)
*
0
1
2
3
4
5
6
7
8
9
10
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
*
I AGREE
Signature authenticating all above here please
*
clear
Enter the word in the image. THIS HELPS TO CONFIRM THAT YOU ACTUALLY COMPLETED THIS FORM
*
thank you for your responses tf medical "lives serving lives"