Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Addiction Medicine Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Primary Substance of Use
Substance Use History
Withdrawal Symptom Assessment
Prior Overdose History
Additional details
Prior Treatment Episodes
MAT History
Mental Health Comorbidities
Housing & Employment Status
Legal Involvement
Recovery Support System
Readiness for Change
Consent & Signature
Date
Addiction Medicine Intake Form template from formisoft.com. formisoft.com/intake-templates/addiction-medicine-intake