Therapy Progress Note
Suboxone Therapy Progress Note:{formdate: \ MM/DD/YYYY}
The visit was conducted by telehealth for buprenorphine refill.
| 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} |
| My joints hurt | {formmenu: default=0; 1; 2; 3; 4; 5} | 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 drugs since your last visit? {formmenu: Yes; default=No; name=}
If 'yes' please describe what, when, and how much
{formparagraph: name=Confessed usage}
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; CVS Greenwood; Condon's; Other:\ }{formtext: name=Other pharmacy}
Drug test:
When was your last one? {formmenu: default=Not Done; Today; Yesterday; I'll do it by tomorrow.}
Results: {formmenu: Appropriate; Inappropriate; default=Not done; 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; Warrington, Clarksdale; Sharkey CC, Rolling Fork; NSMC, Ruleville; LabCorp; Other:\ ; name=UDS locations} {formtext: name=Other UDS location}
Security:
Who is in the area with you?{formmenu: default=None\ ; Family member; Boyfriend/girlfriend; Coworker} We can talk openly.{formtoggle: name=; default=yes}{endformtoggle}
Where are you right now?{formmenu: default=Private location; Home; Work\ ; Car (but not driving).}
Are you using public WiFi?{formmenu: Yes; default=No; }
PMP checked and showed {formmenu: default=no other prescribers or other medications.; another approved provider/medication.; violation(s).}{formtext: name=List any violation?}