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New Patient Pre-Visit Questionnaire

First name

Last name

Phone

Birthday

Month

Day

Year

Past Medical History

Multi choice

High Blood Pressure

Diabetes (Type 1 or 2)

Asthma / COPD

Heart Disease/ Heart Attack

Stroke

Hepatitis A/B/C

HIV/AIDS

Chronic Pain

Mental Health Disorders (Drpression, Anxiety, Bipolar etc.)

Other, please specify with provider during visit

Past Surgical History

Please list any surgeries and procedures you have had

Opioid Use History

Have you ever used prescription opioids (e.g., Percocet, Oxycodone)?

If yes, when did you start?

Are you currently taking prescription opioids?

Have you ever used illicit opioids (e.g., heroin, fentanyl)?

Preferred route of use:

Oral

Nasal/Snorting

Smoking

Injection

Have you ever overdosed?

If yes, how many times?

Other Substance Use

Please indicate any current or past use:

Alcohol

Past Use

Currently Using

Frequency/Amount

Tobacco

Past Use

Currently Using

Frequency/Amount

Marijuana

Past Use

Currently Using

Frequency/Amount

Cocaine/Crack

Past Use

Currently Using

Frequency/Amount

Methamphetamine

Past USe

Currently Using

Frequency/Amount

Other Substance (specify what kind, Frequency/Amount ):

Past MAT (Medication-Assisted Treatment) History

Have you ever been on MAT (e.g., Suboxone, Methadone, Vivitrol)?

What medication(s) have you tried?

When did you start and stop each?

Were they helpful?

If stopped, why?

Social History

Living situation

Employment status

Relationship status

Children

If yes, how many and their ages?

History of incarceration?

History of abuse/trauma?

Physical

Sexual

Emotional

None

Family History

Do any of your biological family members have a history of the following?

Substance Use Disorder

Relation(e.g., mother, father, sibling)

Mental Illness

Relation(e.g., mother, father, sibling)

Heart Disease

Relation(e.g., mother, father, sibling)

Diabetes

Relation(e.g., mother, father, sibling)

Cancer

Relation(e.g., mother, father, sibling)

Other (specify):

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ADVERSE CHILDHOOD EXPERIENCES QUESTIONNAIRE

First name

Last name

Birthday

Month

Day

Year

What does your ACE score mean?

As your ACE score increases, so does the risk of disease, social, and emotional problems. You may want to think about it as a way of measuring the amount of toxic stress you endured as a child and a way of alerting yourself to some statistical indicators of health risks.

The higher your ACE score the higher your chance of suffering from a range of psychological and medical problems like chronic depression, cancer, or coronary heart disease.

However, there are still some serious consequences of a lower score. A quarter of Americans have an ACE score of only one and their chance of becoming an alcoholic doubled. An ACE score of two means four times the risk of alcoholism and an ACE score of 3 may explain your chronic depression.

Knowing what your ACE score means being able to understand your risks and being able to prevent the possible consequences.

An ACE score is a tally of different types of abuse, neglect, and other hallmarks of a rough childhood. According to the Adverse Childhood Experiences study, the rougher your childhood, the higher your score is likely to be and the higher your risk for later health problems.

Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list below, please place a checkmark next to each ACE category that you experienced prior to your 18th birthday. Then, please add up the number of categories of ACEs you experienced and put the total number at the bottom.

Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had

no one to protect or take care of you?

Did you lose a parent through divorce, abandonment, death, or other reason?

Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

Did you live with anyone who went to jail or prison?

Did a parent or adult in your home ever swear at you, insult you, or put you down

Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

Did you feel that no one in your family loved you or thought you were special?

Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?

Your ACE score is the total number of checked responses.How many checkboxes are checked?

Are you Interested in trauma informed care?

Would you like additional resources for trauma informed care?

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Pre-visit Questionnaire for counseling session

As part of the intake process for Suboxone treatment, we ask a series of important questions to better understand your history, current needs, and overall goals for recovery. These questions help your counselor determine if additional services or resources may be beneficial to support your treatment journey. Even if you are familiar with Suboxone treatment or are transferring from another clinic, completing these questions is essential for tailoring the therapeutic process to meet your individual needs and ensure you receive comprehensive care.

Today's Date *

Month

Day

Year

First name*

Last name*

Race*

Gender*

Age*

Reason for seeking treatment:*

Substance Use History

Are you transferring your care from another clinic: (Yes/ No) If yes, Please list the provider name, address, clinic name, and how long were you a patient there.*

Were you ever discharged from any treatment program: (Yes/ No) If yes Why:

Did you abuse prescription drugs? (Yes/ No)

Yes

No

Substance use-frequency/intensity/duration:

Have you struggled with both Alcohol and/or other drugs: (Yes/ No) If yes, what are some other drugs that you struggle with?

Have you ever tried to quit on your own? (Yes/ No) Please describe:

What age were you when you began using (marijuana, or other illicit substances: *

Was your use of illicit substances recreational, or injury related?

Recreational

Injury Related

Did you snort, orally ingest, smoke, and/ or IV use?

Snort

Orally ingest

Smoke

IV use

Do you attend any substance abuse support groups online or in person? If yes, which groups?

Are you facing any legal matters for any illicit substances or/ alcohol abuse? If yes, provide details:

Are you currently on probation either from a (State or Federal) institution? (If yes) for how long?

Did you use a combination of illicit drugs (Yes/ No) If yes what combinations:

How much illicit substances would you consume in a day?

How long have you been or had been using illegal substances or misused prescription drug?

Do you smoke? If yes, how much

Do you want to quit smoking?

Yes

No

Treatment history (Mental Health and Substance Abuse Treatment)

Have you ever been treated for substance dependence or misuse (e.g. detoxification program, Intensive Outpatient Program, Individual Therapy?) (if yes, please describe setting, length):

Have you ever experienced mental, verbal, emotional, physical, and/or sexual abuse? Please describe below:

Social Family History ( Mental Health and Substance Abuse)

Does anyone in your family (mother, father, brother/sister, child, aunt/uncle or grandparent) have a history of substance abuse? If yes, please describe below:

Has anyone in your family (mother, father, brother/sister, child, aunt/uncle or grandparent) ever been diagnosed with a mental health disorder? If yes, please describe below

Mental Health & Sexuality

Do you have trust concerns? If yes, please explain:

Do you have weight concerns?

Yes

No

Are you on diet pills or weight loss injections?

Yes

No

Are you under psychiatric care? Are your needs being met? If yes by whom?

Do you struggle with sexual identity?

Yes

No

How do you sexually self- identify:

Straight

Bi-Sexual

Homosexual

Transgender

Are you a part of any LGBT or QIA support group

Yes

No

Are you sexually active?

Yes

No

Do you use protection?

Yes

No

Are you effectively communicating well with others?

Yes

No

Any relationships in the past abusive? If yes, please explain:

Have you ever attempted suicide? If yes, please explain:

Have you ever felt like you wanted to self-harm ? If yes, please explain:

Have you cut yourself in the past? If yes, please explain:

Do you prefer to be alone:

Yes

No

Have you been clinically diagnosed with depression? If yes, by whom

Have you been clinically diagnosed with anxiety? If yes, by whom

Have you ever physically hurt others? If yes, please explain:

Do you have any other Mental Health concerns: (For example: Bipolar, Schizophrenia, PTSD, Panic Attacks, or Night terrors)

Have you been diagnosed with an eating disorder ?If yes, please explain:

Have you been diagnosed with a sleep disorder?

Narcolepsy

Insomnia

Sleep Apnea

None of the above

Have you ever experienced hallucinations? If yes, please explain:

Have you ever experienced auditory voices? If yes, please explain:

Social History, Educational/Occupational History, and Legal Concerns

Has your substance abuse impacted your relationships, made work difficult for you and/or led to legal issues in the past or currently? (Yes/No) If yes, please describe:

Level of education completed?

Community, Environment & Employment

Do you have a job? (Yes/ No) how long have you had this job?

How many jobs have you worked in over the past 2 years:

Do you attend any religious services:

Yes

No

Are you active in any community volunteer services or any form of community service? (Yes/ No) If yes, please explain:

Are you on disability?

Yes

No

Living situation

Own

Rent

Homeless

Other

Is this a stable accommodation for you? (Yes/ No) If no, please explain:

How long have you lived there?

Do you live with someone: (Yes/ No) if yes, (Who)

Relationships

Relationship Status

Married

Divorced

Single

Widowed

In a long-term Relationship

Separated

Where do you live (What County)

What are your relationships like at home?

Is domestic violence, either physical, emotional, or psychological abuse occurring? (Yes/No) If yes, please explain:

Do you feel secure and safe at home? (Yes/No) If no, please explain:

Is your family, and/or friends supportive of your recovery efforts (Yes/No) If no, please explain:

Do you have friends you hang out with?

Yes

No

Have you been incarcerated/ or gone to jail: (Yes/ No) If yes, provide details:

Are you trying to mend broken family relationships (Yes/ No) If yes, please explain:

Medical Conditions

Do you have any medical conditions? (Yes/No) If yes list below and include any medications that you are taking currently as well as the dosage:

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Phone :615-375-1188

Fax: 615-375-1290

foreverwelldickson@gmail.com

118 Highway 70 East Unit #1

Dickson TN 37055

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