Suboxone template
Suboxone Therapy Progress Note:{formdate: \ MM/DD/YYYY}
| I feel anxious | {formmenu: default=0; 1; 2; 3; 4; 5} | I feel nauseated or like I may need to vomit | {formmenu: default=0; 1; 2; 3; 4; 5} |
| I feel like yawning | {formmenu: default=0; 1; 2; 3; 4; 5} | I have stomach cramps and/or diarrhea | {formmenu: default=0; 1; 2; 3; 4; 5} |
| I Have a headache | {formmenu: default=0; 1; 2; 3; 4; 5} | I feel dehydrated and/or have not had much appetite | {formmenu: default=0; 1; 2; 3; 4; 5} |
| I am perspiring | {formmenu: default=0; 1; 2; 3; 4; 5} | I am having difficulty sleeping | {formmenu: default=0; 1; 2; 3; 4; 5} |
| My muscles twitch | {formmenu: default=0; 1; 2; 3; 4; 5} | My nose is running and/or my eyes are watery | {formmenu: default=0; 1; 2; 3; 4; 5} |
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I have goosebumps and/or chills | {formmenu: default=0; 1; 2; 3; 4; 5} |
I feel like using now {formmenu: default=0; 1; 2; 3; 4; 5}
I would rate my overall level of withdrawal as {formmenu: default=0; 1; 2; 3; 4; 5}
Do you feel like you need a dosage change? {formmenu: default=No; Yes - Go up; Yes - Go down}
Have you used alcohol or dugs since your last visit? {formmenu: Yes; default=No; name=}
If 'yes' please describe what, when and how much
{formparagraph: name=Illicit Usages}
Please describe the problems or situations you found most stressful during the past week.
{formparagraph: name=Stressful situations}
Pharmacy: {formmenu: Walmart Indianola; Martin's; default=Brown's Greenville; Kroger Greenville; Walgreen's Greenville; CVS Greenville; Greenwood Downtown Drug; Kroger Batesville; Kroger Granada}{formtext: name=Other pharmacy}
Drug Screen: {formmenu: default=Appropriate; Inappropriate; ; name=UDS} {formtext: name=If inappropriate, how?}
Where do you do your drug tests? {formmenu: default=IFMG Indianola; Family Medical Clinic, Greenville; Byrd Clinic, Clarksdale; UMMC, Grenada; NSMC, Ruleville; Other; name=UDS locations} {formtext: name=Other UDS location}