Inland Family Practice Center, LLCQuality Health Care for the Whole Family Ikechukwu Okorie, MD423 Weathersby Rd, Suite 200Hattiesburg, MS 39402601-544-7012 Suboxone Intake Questionnaire A. Personal Information Full Name Date of Birth: Contact Information Phone Email Address Insurance Information (if applicable): B. Substance Use History 1. Opioid Use: Which opioids have you used? (e.g., oxycodone, heroin, prescription painkillers) When did you first start using opioids? Current frequency and amount used (e.g., number of pills, daily cost) When was your last opioid use? 2. Previous Treatment Attempts: Have you ever received treatment for opioid dependency (e.g., methadone, buprenorphine/Suboxone, rehab programs)? Yes No If yes, please describe the treatment(s) and outcomes: 3. Other Substance Use: Have you used any other substances (e.g., cocaine, benzodiazepines, alcohol)? Yes No If yes, list the substances and frequency of use: C. Current Symptoms & Withdrawal 1. Withdrawal Symptoms: (Check all that apply) Restless legs Upset stomach Headaches Night sweats Nausea AnxietyOther 2. Craving Assessment: On a scale of 1–10, how intense are your cravings right now? 3. Self-Management: What strategies have you used in the past to manage withdrawal or cravings? D. Medical & Psychiatric History 1. Current Medications: List any medications you are taking: 2. Medical Conditions: Do you have any chronic conditions? (e.g., diabetes, liver disease) 3. Psychiatric History: Have you been diagnosed with any mental health conditions (e.g., depression, anxiety)? Yes No If yes, please list and describe: E. Social & Legal History 1. Employment Status: Current employment status: Employed Unemployed Student Other 2. Living Situation: Please describe your current housing and support system: 3. Legal Involvement: Have you had any legal issues related to substance use (e.g., DUI, court-mandated treatment)? Yes No If yes, please provide details: F. Treatment Goals & Expectations 1. Motivation for Treatment: What are your goals in starting Suboxone treatment? 2. Expectations What do you hope to achieve with this treatment? 3. Additional Support: Are you interested in counseling or support groups as part of your recovery? Yes No G. Consent & Acknowledgment I understand the benefits and risks of Suboxone treatment and agree to participate in thistreatment program. Patient SignatureClear Date Submit
