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Opiate Risk Evaluation

READ THIS CAREFULLY.
 
This questionnaire collects personal information that will be provided to your physician and may be added to your medical record.
 
Your results will be shared with the individual(s) necessary to process any Workers' Compensation or similar claims (if applicable).
 
Your information will be protected and maintained in compliance with HIIPAA guidelines for data security.
Sign Consent Electronically
First Name:
Last Name:
How often do you have mood swings?
Never
Seldom
Sometimes
Often
Very Often
How often have you felt a need for higher doses of medication to treat your pain?
Never
Seldom
Sometimes
Often
Very Often
How often have you felt impatient with your doctors?
Never
Seldom
Sometimes
Often
Very Often
How often have you felt that things are just too overwhelming that you can't handle them?
Never
Seldom
Sometimes
Often
Very Often
How often is there tension in the home?
Never
Seldom
Sometimes
Often
Very Often
How often have you counted pain pills to see how many are remaining?
Never
Seldom
Sometimes
Often
Very Often
How often have you been concerned that people will judge you for taking pain medication?
Never
Seldom
Sometimes
Often
Very Often
How often have you feel bored?
Never
Seldom
Sometimes
Often
Very Often
How often have you taken more pain medication than you were supposed to?
Never
Seldom
Sometimes
Often
Very Often
How often have you worried about being left alone?
Never
Seldom
Sometimes
Often
Very Often
How often have you felt a craving for medication?
Never
Seldom
Sometimes
Often
Very Often
How often have others expressed concern over your use of medication?
Never
Seldom
Sometimes
Often
Very Often
How often have any of your close friends had a problem with alcohol or drugs?
Never
Seldom
Sometimes
Often
Very Often
How often have others told you that you had a bad temper?
Never
Seldom
Sometimes
Often
Very Often
How often have you felt consumed by the need to get pain medication?
Never
Seldom
Sometimes
Often
Very Often
How often have you run out of pain medication early?
Never
Seldom
Sometimes
Often
Very Often
How often have others kept you from getting what you deserve?
Never
Seldom
Sometimes
Often
Very Often
How often, in your lifetime, have you had legal problems or been arrested?
Never
Seldom
Sometimes
Often
Very Often
How often have you attended an AA or NA meeting?
Never
Seldom
Sometimes
Often
Very Often
How often have you been in an argument that was so out of control that someone got hurt?
Never
Seldom
Sometimes
Often
Very Often
How often have you been sexually abused?
Never
Seldom
Sometimes
Often
Very Often
How often have others suggested that you have a drug or alcohol problem?
Never
Seldom
Sometimes
Often
Very Often
How often have you had to borrow pain medications from your family or friends?
Never
Seldom
Sometimes
Often
Very Often
How often have you been treated for an alcohol or drug problem?
Never
Seldom
Sometimes
Often
Very Often
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