formisoft

Addiction Medicine Intake Form

Asks about primary substance of use, substance use history, and withdrawal symptom assessment. Built for addiction medicine and medication-assisted treatment programs.

Questions
16
Pages
2
Time
about 4 min

Includes

  • E-signature
Use this templatePrint it instead

Your practice

Addiction Medicine Intake Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Addiction medicine and medication-assisted treatment programs
  • Opioid treatment programs and buprenorphine clinics
  • Residential and intensive outpatient substance use treatment
  • Integrated primary care and addiction medicine practices

What's inside

Page 1 · Your information

  1. Full NameText · Required
  2. Date of BirthDate
  3. Phone NumberPhone
  4. Email AddressEmail
  5. Primary Substance of UseLong Text

Page 2 · Additional details

  1. Prior Treatment EpisodesLong Text
  2. MAT HistoryLong Text
  3. Mental Health ComorbiditiesLong Text
  4. Housing & Employment StatusLong Text
  5. Legal InvolvementLong Text

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Addiction Medicine Intake Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

All templates

Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Addiction Medicine Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

Use this template