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Opioid Risk Tool

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
Today's date?
First Name
Last Name
My age is between 16 years old and 45 years old.
Yes
No
Gender
Male
Female
Family History of alcohol abuse.
Yes
No
Family History of illegal drugs Use.
Yes
No
Family History of prescription drug abuse.
Yes
No
I have a history of alcohol abuse.
Yes
No
I have a history of illegal drug use.
Yes
No
I have a history of prescription drug abuse.
Yes
No
I have a history of preadolescent sexual abuse.
Yes
No
I have one or more of the following conditions:

Attention Deficit Disorder
Obsessive Compulsive Disorder
Bipolar
Schizophrenia
Yes
No
Family History of alcohol abuse
Yes
No
Family History of illegal drug abuse
Yes
No
Family History of prescription drug abuse
Yes
No
I have a history of alcohol abuse
Yes
No
I have a history of illegal drug abuse
Yes
No
I have a history of prescription drug abuse
Yes
No
I have a history of preadolescent sexual abuse
Yes
No
I have one or more of the following conditions:

Attention Deficit Disorder
Obsessive Compulsive Disorder
Bipolar
Schizophrenia
 
Yes
No
I have a history of depression
Yes
No
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