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Home
About Us
Our Facility
Meet Our Team
Treatment Areas
Back Pain
Neck Pain and Headaches
Shoulder Pain
Elbow Pain
Wrist/Hand Pain
Hip Pain
Knee Pain
Sports Injuries
Fibromyalgia
Specialties
Medication Management
Interventional Pain Procedures
Medical Weight Loss
Sleep Management
For Patients
Patient Forms
Blog
Lectures
Videos
Testimonials
Physicians
Referrals
Education and Training
Contact Us
Opioid Assessment
Opioid Assessment
Zahid Ramzan
2022-10-21T23:02:15+00:00
Opioid Assessment
Please check all boxes that apply to you under your gender.
Name
First
Last
Date
MM slash DD slash YYYY
Mark each box that applies to you under your gender
Gender
Male
Female
Family History of Substance abuse
Alcohol
3
Alcohol
1
Illegal Drugs
3
Illegal Drugs
2
Rx Drugs
4
Rx Drugs
4
Personal History of Substance abuse
Alcohol
3
Alcohol
3
Illegal Drugs
4
Illegal Drugs
4
Rx Drugs
5
Rx Drugs
5
Age Between 16-45 yrs
1
History of Preadolescent Sexual Abuse
0
History of Preadolescent Sexual Abuse
3
Psychologic Disease
ADD, OCD, Bipolar, Schizophrenia
2
Depression
1
Scoring Totals
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