08.011 Physical Assesment fORM

RECOVERY WORKS

Physical Assessment

b.1a.f

Name Date Date of Birth Primary Care Physician

Medications

List ALL current medications, supplements, vitamins, over-the-counter, and how often you take them:

Medication Name Dose Frequency Prescribed

▢ Yes ▢No

▢ Yes ▢No

▢ Yes ▢No

▢ Yes ▢No

▢ Yes ▢No

Alcohol and Drug Abuse

Do you drink alcohol? ▢ Yes ▢ No If Yes, when was the last time you drank alcohol? If Yes, how often and how much do you drink? Do you use any illegal drugs, or take medications not prescribed to you? ▢ Yes ▢ No If, yes please answer below:

Drug Name How Often How Much

Last Use within seven days ▢ Yes ▢ No Last Use within seven days ▢ Yes ▢ No Last Use within seven days ▢ Yes ▢ No Last Use within seven days ▢ Yes ▢ No

Tobacco History

Have you ever smoked cigarettes? ▢ Yes ▢ No Currently? ▢ Yes ▢ No

If Yes, how many packs per day on average? For how many years?

Medical History

Allergies Current Weight Height Do you have any trouble walking, writing, speaking, hearing, or seeing? ▢ Yes ▢ No If Yes, please explain

Are you currently being treated for an infectious disease such as, but not limited to MRSA, HIV, AIDS, Hepatitis, and / or

Tuberculosis? ▢ Yes ▢ No If Yes, please explain.

Have you ever been treated for any of the following:

Please list any past surgeries

Physical Assessment

Is the client alert and oriented to person place time and situation? ▢ Yes ▢ No

Breathing within normal limits ▢ Yes ▢ No Nutrition within normal limits ▢ Yes ▢ No Bowel / Bladder function within normal limits ▢ Yes ▢ No Musculoskeletal within normal limits ▢ Yes ▢No Any open wounds ▢ Yes ▢ No Circulation within normal limits ▢ Yes▢No Respirations within normal limits ▢ Yes ▢ No Dental problems ▢ Yes▢No

If No, please explain.

For women only

Date of last menstrual period Are you currently pregnant or could you be pregnant? ▢ Yes ▢ No. Are you planning to get pregnant in the near future? ▢Yes ▢ No Birth control method

Suicide Risk Assessment

1. Have you recently had feelings, or thoughts that you didn't want to live? ▢ Yes ▢No. If yes, please explain

2. Have you recently tried to kill or harm yourself before? ▢ Yes ▢ No If yes, please explain.

Vital Signs

Blood pressure / Pulse Respirations Pulse Oximetry Temperature

History Completed by: Date:

To Be Completed by Physician, Registered Nurse, or LPN Under a Physican's Supervision

Based on your assessment, are there any concerns that need to be addressed before the client attends a substance abuse p rogram? ▢ Yes ▢ No I f Y es, please explain.

Based on your assessment, is there any reason why the client cannot participate in a substance abuse recovery program? ▢ Yes ▢ No I f Y es, please e xplain.

Based on your assessment, does the client require detox from Benzodiazepines, or Alcohol before going to a substance abuse r ecovery p rogram?I ▢ Yes ▢ No I f Y es, please e xplain.

I have reviewed this assessment and have met with the client at Admission. (See attached Provisional Diagnosis and Placement }

Printed name and title of Physician

Physician's Signature:

Date:

Page | 2

Provisional Diagnosis and Placement Level

Alcohol Use Disorder (ICD 10)

305.00 (F10.10) Mild

2-3 symptoms present

Stimulant Use Disorder

303.90(F10.20)

Moderate

4-5 symptoms present

Mild: Presence of 2-3 symptoms

303.90(F10.20) Severe

Phencyclidine Use Disorder

6+ symptoms present

305.70

(F15.10)

Amphetamine-type substance

305.90 (F16.10)

Mild

2-3 symptoms present

Moderate: Presence of 4-5 symptoms

304.60 (F16.20)

304.60 (F16.20)

Moderate Severe

4-5 symptoms present

6+ symptoms present

304.40 (F15.20)

Amphetamine-type substance

Inhalant Use Disorder:

Severe: Presence of 6 or more symptoms

305.90 (F18.10)

304.60 (F18.20)

Mild Moderate

2-3 symptoms present

4-5 symptoms present

304.40

(F15.20)

Amphetamine-type substance

304.60 (F18.20) Severe

Cannabis Use Disorder

6+ symptoms present

305.20 (F12.10)

Mild

2-3 symptoms present

Sedative, Hypnotic, or Anxiolytic Use Disorder

304.30 (F12.20)

Moderate

4-5 symptoms present

305.40 (F13.10)

Mild

2-3 symptoms present

304.30 (F12.20) Severe

6+ symptoms present

304.10 (F13.20)

Moderate

4-5 symptoms present

Other Hallucinogen Use Disorder

304.10 (F13.20) Severe

6+ symptoms present

Screening of substance use revealed insufficient symptoms to indicate abuse or addiction.

Initial Withdrawal Level (Mark One or Choose Refer to Higher Level of Care)

Refer to higher level of care

Initial Placement Level (Choose One or Choose Refer to Higher Level of care)

Refer to higher level of care

Signature and Credential: Date: