Stimulant Screening and Intake Form

1 of 4 - PERSONAL INFORMATION

Required Field

Patient Legal Name

First

Last

Previous Coleman Patient? Yes No

Year

Referred by

Please share the name of the referrer

Primary Phone Number

Phone Type

DOB

Height

Weight

Race/Ethnicity White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Prefer not to respond

Gender Male Female Transgender Non-binary/non-conforming Prefer not to respond

Address

City

State

Zip

Email Address

Alt. Email Address

Please note: An email will be sent from The Coleman Institute to the above address/addresses which will include sensitive information.

Are you covered by Medicare? Yes No

Tentative Start Date

Support Person

Relationship

Support Person's Phone

Screened By Jennifer Amy Jen Jacqueline

Desired Location

2 of 4 - HISTORY OF USE

Stimulant History

First type of stimulant used

Age when started

Reason

Date you became dependent (began having withdrawal symptoms)

Have you been abstinent from stimulant for any period of time? Yes No

If yes, how long?

Time since last period of abstinence (greater than 1 week of no stimulant)

What is the date of your last stimulant use (including Adderall, methamphetamine, amphetamine, cocaine, MDMA))?

Describe:

Other Drug History

Previous Alcohol:

Age:

to:

Current Alcohol:

Describe:

Previous Marijuana:

Age:

to:

Current Marijuana:

Describe:

Previous Benzodiazepines:

Age:

to:

Current Benzodiazepines:

Describe:

Previous Other:

Age:

to:

Current Other:

Describe:

Previous Opioid Use:

Current Opioid Use:

3 of 4 - MEDICAL HISTORY

Primary Care:

Primary Care Physician's Name and Phone Number

I do not have a PCP at this time:

Past Medical History (Select All That Apply):

Cardiac or Hypertension?

Explain:

Diabetes?

Explain:

Respiratory?

Explain:

Problems with Anesthesia or Sedatives?

Explain:

Head Injuries?

Explain:

Problems with Snoring/ Sleep Apnea?

Explain:

Previous DTs (Confusion with Tremors)?

Explain:

Seizures?

Explain:

Steroid Use?

Explain:

Liver Problems, Hepatitis, Cirrhosis, Ascites

Explain:

Pancreatitis?

Explain:

Skin Infections / MRSA?

Explain:

Past Surgeries?

Explain:

4 of 4 - SOCIAL HISTORY

Other alcohol or drug use in the home:

Employment Status

More Recent Employment

Type of work:

Pregnant?

Date of Last Menstrual Period

Using birth control?

Do you have a Naloxone rescue kit?

If you do not have a Naloxone rescue kit we recommend getting one as soon as possible.

Do you know if there is a needle exchange program nearby?

If you inject drugs we recommend you check out NASEN – the North American Needle exchange Network – to find a location close to you.

Please Initial:

I understand that any missing or false information may result in a schedule change or cancellation.

I understand that I need to review this medical information by phone with a treating practitioner before starting my detox.

Thank you for your submission.

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