In the past 24 hours have you experienced any of the following symptoms?

In the past 24 hours have you experienced any of the following symptoms>

*Fever of above 100.5 degrees or above, or alternating between sweating and chills *New trouble breathing, shortness of breath or severe wheezing *New muscle aches *New loss of smell or taste, or a change in taste *New cough *New chills *Diarrhea *None of the above *Other (explain below)

Other

Have you been tested for COVID-19 within the last two weeks?

Have you been tested for COVID-19 within the last two weeks

Yes No

Results of Covid Test

Treatment History

Have you ever been treated in our program? If yes, Include date and reason for discharge

Have you ever been treated in our program

Are you in treatment at another agency? If yes, what program and length of treatment

other program and length

Prior Treatment History

Prior Treatment History

Any chronic medical conditions? If yes, explain condition and medications

chronic conditions

Have you ever been diagnosed with a mental health disorder? If yes, what was the diagnosis, by whom, any medications?

mental disorder

Are you or is there any chance you could be pregnant?

Pregnant?

Yes No

If yes, due date

due date

Are you currently using substances? If so, select below

substance selection

Opiates Cocaine Benzos Amphetamines Alcohol THC None Other (describe below)

Please describe: Primary, secondary drug, frequency of use, route (IV, inhale, etc.) 

Have you had any overdoses in the last 30 days ? (FOR MAT APPOINTMENTS)

overdoses desc

Referred by:

Referred by:

Self IME Clinic Friend/Family Drug Court Work First NJ Legal (Probation/Lawyer/Parole) DCPP IDRC (Intoxicated Driver Resource Center) Other (describe below)

other referrals:

Other Input:

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