Suboxone Progress Form
Please Fill Below Form
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GENERAL INFORMATION
What Medications and Dosages are you currently taking?
Sobriety Date (If Known)
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How Many 12 Step Meetings in Past 30 Days?
Any Use of Alcohol, Marijuana or Other Drugs Since Last Encounter?
*
If so, What substances did you use?
*
Marijuana
Alcohol
Opiates
Benzodiazepines
Stimulants
Cocaine
Soma
MDMA
Barbiturates
The following questions: 1 - 10 (1=Low / 10=High)
How Much Withdrawal Symptoms Have You Been Having?
*
How do you rate your current stress levels
*
How do you rate your current level of energy or vitality
*
Have You Been Feeling Depressed Lately? How Much?
How many hours sleep do you get a night?
*
Do you have trouble getting to sleep?
*
No
Yes
Do you wake often, or get woken easily?
*
Yes
No
Have You Been Having Any Cravings To Use Drugs or Alcohol?
*
Yes
No
How Much Cravings Have You Had?
Have You Been Seeing a Therapist Or Counselor?
*
Yes
No
Not sure
If Female Have You Missed a Period or Could You POSSIBLY Be Pregnant?
*
Yes
No
Male
Which Medications Do You Need Refilled Now?
*
What is the Phone Number of your Pharmacy
Additional info you might want to share
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