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?
Have you had previous methadone treatment?
Are you currently in methadone treatment?
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))
If yes, which one?
Have you ever tested positive for Tuberculosis (TB)?
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?
Have you been tested for COVID-19?
Have you been fully vaccinated?