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Provider Pre visit questionnaire 

​Please complete the questionnaire below before your visit to help save time and enhance the quality of your care.

Birthday
Month
Day
Year

Past Medical History

Multi choice

Past Surgical History

Opioid Use History

Have you ever used prescription opioids (e.g., Percocet, Oxycodone)?
Are you currently taking prescription opioids?
Have you ever used illicit opioids (e.g., heroin, fentanyl)?
Preferred route of use:
Have you ever overdosed?

Other Substance Use

Please indicate any current or past use:

Past MAT (Medication-Assisted Treatment) History

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

Social History

Living situation
Employment status
Relationship status
Children
History of abuse/trauma?

Family History

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


Substance Use Disorder
Mental Illness
Heart Disease
Diabetes
Cancer
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