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MAT Intake
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* Indicates required question
Full Legal Name
*
Your answer
First Name Used (If Different):
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Mobile Number
*
Your answer
Email Address
*
Your answer
Home Address
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone
*
Your answer
Insurance Policy Holder Name
Your answer
Policy Holder Date of Birth
MM
/
DD
/
YYYY
Preferred Pharmacy Name & Address
*
Your answer
Do you have any medication allergies?
*
Yes
No
If yes to allergies - please list medication and reaction:
Your answer
What brings you here today?
*
Your answer
Are you currently taking any medication, vitamins or supplements?
*
Yes
No
If so, please list any medications prescribed or OTC also include any vitamins or supplements (include dosages):
Your answer
Use History (Please list substance, years/months of use, route of administration, amount of use):
*
Your answer
When did you last use?
*
Your answer
History of treatment:
*
Your answer
History of psychiatric diagnoses and/or treatment:
*
Your answer
History of Medical Conditions
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Your answer
History of Surgeries or Hospitalizations?
Your answer
Check if you have/had any of the following:
*
Hepatitis
Subacute bacterial endocarditis
HIV
Tuberculosis
STD
Liver disease
None of the above
Required
Drug Abuse History (Please specify to clinician whether past or present):
*
Cocaine
Stimulant (Adderall)
Alcohol
Benzodiazepines
Marijuana
Caffeine
Nicotine/Cigarettes
Other:
Required
Are you sexually active?
*
Yes
No
If so, with men, women, or both?
*
Men
Women
Both
Prefer not to say
Request STI testing?
*
Yes
No
Anything else you would like to share?
Your answer
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