Example of an opioid use disorder treatment patient intake form

Substance use history
Substance used	Age of first use	Amount of most use	Period of most use (date)	Route of administration		Use in last 30 days (# days)	Use in last 30 days (quantity)	Date of last use
				Past	Current
Heroin
Nonprescribed methadone
Nonprescribed buprenorphine
Other nonprescribed opioids (eg, oxycodone)
Cocaine/crack
Methamphetamine
Benzodiazepines
Alcohol
Cannabis
Other (eg, PCP/LSD/ecstasy/MDMA/synthetic cannabis):						Cigarettes:
History of overdose:
HIV status (include most recent HIV test if known):
HCV status (include most recent HCV test if known):
Substance use disorder treatment history
Name of program:		Type of treatment:		Period of attendance:		Outcome (completed/discharged):
Most recent treatment:
Previous treatment:
Longest duration of time abstinent: What helped?
Mental health
Diagnosis:
Psychiatric medications:
Psychotherapy or counseling (current):
Visual and/or auditory hallucinations:
Suicidal thoughts and/or attempts:
Psychiatric hospitalizations:
Social history
Sexual health and birth control use:
Legal issues (eg, parole, probation, mandates):
History of incarceration (months incarcerated, latest release):
Current housing:
Employment:
Family/children/social supports:
Education/literacy:

PCP: phencyclidine; LSD: lysergic acid diethylamide; MDMA: 3,4-methylenedioxymethamphetamine; HCV: hepatitis C virus.

Reproduced with permission from Tiffany Lu, MD, Aaron Fox, MD, and Melissa Stein, MD.

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