Addiction Medicine Intake Form

The Addiction Medicine Intake Form is designed for addiction medicine specialists and medication-assisted treatment programs, capturing the comprehensive substance use and recovery history needed for evidence-based treatment planning. This template collects patient demographics alongside a detailed substance use assessment including primary and secondary substances of use, route of administration, frequency and quantity, age of first use, duration of use, longest period of sobriety, most recent use, prior overdose events, and withdrawal history. The validated screening instruments embedded in the form help quantify substance use severity and guide level-of-care determination.

Built for addiction medicine practices, opioid treatment programs, buprenorphine and naltrexone prescribing clinics, residential and outpatient substance use treatment centers, and integrated primary care-addiction medicine programs, this form includes sections for prior treatment episodes (detoxification, residential, intensive outpatient, outpatient, sober living), medication-assisted treatment history (methadone, buprenorphine/naloxone, naltrexone, disulfiram, acamprosate), co-occurring mental health conditions (depression, anxiety, PTSD, bipolar disorder), legal and criminal justice involvement, social determinants of health (housing stability, employment, family support, childcare needs), recovery capital assessment, and readiness-for-change evaluation.

All fields are HIPAA-compliant and designed with trauma-informed, person-first language that reduces stigma and encourages honest disclosure. The form complies with 42 CFR Part 2 confidentiality requirements for substance use disorder patient records. Pre-visit completion allows the addiction medicine team to assess withdrawal risk, determine appropriate level of care, prepare medication-assisted treatment options, and develop a comprehensive treatment plan that addresses the biological, psychological, and social dimensions of addiction.