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HOME
ABOUT
SERVICES
OUR BENEFITS
SCHEDULE PRE-SCREENING
CONTACT US
Schedule Pre-Screening
Schedule Pre-Screening
Schedule Pre-Screening
admin
2023-01-20T21:12:35+00:00
Date
Your Name
D.O.B
Phone
What drugs are you currently using?
What is your drug of choice?
How often do you use?
How do you use?/Method of ingestion?
Oral
IV
Nasal
Other
Have you had previous methadone treatment?
Yes
No
Are you currently in methadone treatment?
Yes
No
If no, how long ago were you in treatment?
What clinic was previous treatment at?
Are you on any prescribed medications? If yes, what are they?
Are you currently taking any benzodiazepines (prescribed or off the street)? (Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium), Lorazepam (Ativan), Temazepam (Restoril))
Yes
No
If yes, which one?
Have you ever tested positive for Tuberculosis (TB)?
Yes
No
If yes, TRANSFER PATIENT TO MEDICAL.
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
Yes
No
Have you been tested for COVID-19?
Yes
No
Have you been fully vaccinated?
Yes
No
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