Demographic Information Your name DOB: Cell Phone Number: Street Address: City: State: Zip Code: Is it OK to leave a Voice Mail Message? YesNo Emergency Contact Name: Phone: Relationship: 1. Is your Emergency Contact aware of your addiction? YesNo 2. Are you pregnant?YesNoUnsureN/A 3. Are you taking Birth Control Pills?YesNo Drug Use History: What are you currently using at this time? Heroin Amount OxyContin Amount Methadone Amount Percocet, Vicodin, etc. Amount Cocaine Amount Benzos Amount Alcohol Amount Other Amount Drug Use Questionnaire: 1. Have you ever overdosed? YesNo If yes, what is the total number of lifetime overdoses 2. Have you ever been hospitalized due to an overdose? YesNo If yes, were you kept overnight? YesNo If yes, were you intubated? YesNo Substance Abuse Treatment History 1. Have you had any substance abuse treatment?YesNo Program/Treatment Detox Program YesNo How many Times? Residential (Rehab/Halfway House) YesNo How many Times? Outpatient Counseling YesNo How many Times? Buprenorphine/Suboxone Maintenance YesNo How many Times? Methadone Maintenance YesNo How many Times? 12-Step Programs (NA/AA) YesNo How many Times? Acupuncture YesNo How many Times? Other YesNo Name: How many Times? Substance Abuse Questionnaire: 2. How many attempts have you made to get clean? 3. Do you currently attend an AA, NA, or a Similar Program? YesNo 1-23-45-6DailyNoneOther 4. In your program, have you worked the steps? YesNo If yes, what step are you on? 5. Do you have a sponsor? YesNo How often do you have contact with your sponsor? 6. Do you have any history of any other addictive behaviors? GamblingShoppingEat DisorderSexNoneOther Criminal History: 1. Have you ever been arrested? YesNo 2. Have you ever been incarcerated? YesNo If yes, how many times? 3. What is the longest period of time you spent in jail/prison? 4. Are you on probation? YesNo 5. Are you facing any potential jail time? YesNo Clean Time History 1. What was the longest period of time that you have been clean? 2. When was this? 3. What has triggered relapse in the past? Methadone History 1. Have you ever been on Methadone Maintenance? YesNoCurrently 2. When were you on Methadone Maintenance? 3. Where did you get Methadone Maintenance Treatment? 4. How long were you on Methadone Maintenance? 5. What is/was your dose? 6. Why did you stop Methadone Maintenance? 7. What is the name of your counselor at your Methadone Clinic? 8. Are you receiving take-homes? YesNoN/A 9. What has your experience been like while on methadone Maintenance? Extremely PositivePositiveNeutralNegativeExtremely Negative Suboxone History 1. Have you ever been prescribed Suboxone before? YesNoCurrently 2. When were you on Suboxone Maintenance? 3. Where did you get Suboxone Maintenance Treatment? 4. How long were you on Suboxone Maintenance? 5. What is/was your dose? 6. Why did you stop Suboxone Maintenance? 7. What is the name of your counselor at your Suboxone Clinic? 8. Are you receiving take-homes? YesNoN/A 9. What has your experience been like while on Suboxone Maintenance? Extremely PositivePositiveNeutralNegativeExtremely Negative 10. Have you ever tried Suboxone without a prescription? YesNo Mental Health History 1. Have you ever been diagnosed with any mental health condition? YesNo Depression Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo Anxiety Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo Bipolar Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo Schizophrenia Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo Obsessive Compulsive Disorder (OCD) Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo Post-Traumatic Stress Disorder (PTSD) Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo Attention Deficit Disorder (ADD) Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo Panic Attacks Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo Other Are you currently taking medications to manage this/these conditions?YesNo What medication are you taking? Are you currently seeing a psychiatrist, psychologist, or counselor for this/ these conditions?YesNo If you have seen or currently are seeing a psychiatrist, psychologist, or counselor: 2. Where do you see them for treatment or management? 3. What is this individual’s name? 4. How often do you see them? 5. How many times have you seen this person in the last 6 months? times 6. Will you sign a consent to release information so that we can communicate with your psychiatrist, psychologist, or counselor about your treatment plan? YesNo 7. If you are not seeing a psychiatrist, psychologist or counselor, why not? 8. Have you ever been hospitalized for mental health issues? YesNo 9. Have you ever attempted to end your life or hurt yourself? YesNo 10. How many times have you attempted to end your life or hurt yourself? 11. Do you currently have thoughts about hurting yourself or ending your life? YesNo 12. Do you currently have a plan for how you would harm yourself/end your life? YesNo 13. Do you have the means to carry out your plan? YesNo 14. Have you ever attempted or thought about homicide (killing someone else) in the past? YesNo 15. Have you thought about how you would do it? YesNo 16. Are you currently thinking about killing someone? YesNo 17. Do you have the means to carry this out? YesNo 18. Have you been hurt physically, emotionally or verbally by anyone in the last year? YesNo 19. Have you ever been asked to perform sexual acts that you did not want to do? YesNo 20. Do you have any concerns for your personal safety at this time? YesNo Health Status Have you ever been diagnosed with any other medical conditions? Check all that apply. Diabetes Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions High Blood Pressure Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Heart Disease Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Cancer Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Asthma Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Hepatitis C Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Hepatitis A Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Hepatitis B Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions HIV Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Seizure Disorder Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Head Trauma/Injuries Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Pancreatic Problems Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions Other Have You Been Treated or are Currently Under Care?YesNo Please list any medication(s) you are taking to manage/treat these conditions None 1. Have you been tested for HIV? YesNo If yes, when was the last time you were tested? 2. Have you ever had surgery? YesNo If yes, what surgery did you have? 3. Do you have any pending/ upcoming surgeries? YesNo If yes, what surgery and when? & Pain 1. Do you have problems with pain? YesNo 2. Where is your pain located? 3. Has your pain lasted 3 months or longer? YesNo 4. If yes, tell us about your pain. (What it is from, how often do you experience it, how do you deal with it?) 5. Rate your pain on a scale of 0-10 without pain medications. (prescribed or not prescribed) 6. Have you been prescribed any medications for your pain? YesNo 7. Which medication(s) gives you the most pain relief? 8. Have you tried other treatments that did not include medications for your pain? I.e. Acupuncture, physical therapy, steroid injections, behavioral therapy, etc. YesNo Physician Information 1. Where do you get most of your health care? (Facility Name) 2. When was the last time you saw a doctor?Last weekLast monthWithin the last 3 monthsWithin the last 6 monthsWithin the last yearMore than 1year ago 3. What is the name of your doctor? 4. What is their phone number? Fax: Employment 1. Are you currently employed? YesNo If yes, what do you do for work? Full TimePart Time 2. What days of the week do you work? MonTuesWedThurFriSatSun 3. How many hours do you work per day? 4. Are you satisfied with your job? YesNo Social Support 1. What is your relationship status?SingleMarriedLong Term RelationshipDivorcedOther 2. Do you live with your partner/significant other? YesNo 3. Has your partner ever used drugs? YesNoI don't know 4. Is your partner currently in treatment? YesNoI don't know If yes, what kind of treatment are they in? SuboxoneMethadoneOther 5. How satisfied are you with the support you get from your partner? Very SatisfiedSatisfiedNeutralnot Satisfied 6. Do you, or have you ever used it at home? YesNo 7. Is there someone whom you can turn to if you needed help in an emergency or got sick? 8. How is this person related to you? 9. Does this person know about your history of substance abuse? YesNoI don't know 10. Overall, how satisfied are you with the support you get from your friends? Very SatisfiedSatisfiedNeutralnot Satisfied Family History 1. Do any of your family members have a history of substance use/abuse? YesNoN/A 2. If yes, which family members?MotherFatherSilblingGrandparentOther 3. If yes, what are they using?AlcoholBenzosHeroinAmphetamines/ MethamphetaminesCocaineMarijuanaOther 4. How satisfied are you with the support from your family members? Very SatisfiedSatisfiedNeutralnot SatisfiedN/A Transportation 1. How do you get around?I have my own car/I drive MyselfGet a ride from family/ friendsPublic transportationI Walk/ BikeOther 2. Do you have a driver’s license? YesNo 3. Would you be able to come into the office with 48 hours’ notice? YesNo Housing 1. Have you spent one or more weeks on the street or in a shelter in the last 3 months? YesNo 2. What type of residence are you living in now? House/ Apartment that you rentHouse/ Apartment you ownHouse/ Apartment owned or rented my family/ friendsHotelCar/StreetTreatment Program FacilityOther 3. How long have you been staying where you currently live? Years Months 4. Where were you living before? House/ Apartment that you rentHouse/ Apartment you ownHouse/ Apartment owned or rented my family/ friendsHotelCar/StreetTreatment Program FacilityOther 5. How many different places have you lived in the last 12 months? What are your goals for this treatment through HOPE Center?
