Patient Intake Form

Part 1 of 4: Patient Information




If female: Are you pregnant?

Part 2 of 4: Mental Health History

Medication Name

Dose

Frequency

Last Dose

When Prescribed

Part 3 of 4: Substance Abuse History

Primary Substance

Age at first use

Route of Administration

# of days used in past 30 days

Frequency of use in last 6 months

Secondary Substance

Age at first use

Route of Administration

# of days used in past 30 days

Frequency of use in last 6 months

Tertiary Substance

Age at first use

Route of Administration

# of days used in past 30 days

Frequency of use in last 6 months

Part 4 of 4: Substance Abuse Treatment History