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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
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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

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Questions

Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.

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.

Patients open a secure link from an email, a text, or a QR code and complete the form on their phone, tablet, or computer before their appointment. No app download required.

Yes, on Front Desk. 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.

Yes. The Addiction Medicine Intake Form works on any device. Most patients complete intake forms on their phone, so every template is built for small screens first.

Send it before the visit, so patients arrive ready.

Add the Addiction Medicine Intake Form to your account and make it yours in a few minutes.

Cancel anytime · BAA included

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