Health Evaluation Form

GENERAL INFORMATION
What Medications and Dosages are you currently taking?
Sobriety Date (If Known)

Month Day Year
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? *
Do you wake often, or get woken easily? *
Have You Been Having Any Cravings To Use Drugs or Alcohol? *
How Much Cravings Have You Had?
Have You Been Seeing a Therapist Or Counselor? *
If Female Have You Missed a Period or Could You POSSIBLY Be Pregnant? *
Which Medications Do You Need Refilled Now? *
What is the Phone Number of your Pharmacy
Additional info you might want to share
Should be Empty:

Suboxone Progress Form