Rapid Benzodiazepine Detox Screening Form

1 of 5 - PERSONAL INFORMATION

Patient Legal Name

First

Last

Previous TCI Patient? Yes No

Referred by

If Other, please specify

Home Phone

Phone

DOB

Age

Sex

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

Support's Phone

Screened By Jennifer Amy Jen Jacqueline

Desired Location

2 of 5 - USAGE HISTORY

Valium

Xanax

Klonopin

Ativan

Other:

mg per day:

First benzo use:

Age when started:

Reason:

Date you became dependent (had withdrawl symptoms):

Date you first attempted benzodiazepines abstinence:

What have you tried? (how successful)

Date of most recent period of benzodiazepines abstinence:

Previous AA Attendence:

3 of 5 - MEDICAL HISTORY

Other Drug Use (Previous and Current):

Previous Cigarette Smoking:

Current Cigarette Smoking:

Previous Alcohol:

Current Alcohol:

Previous Cocaine:

Current Cocaine:

Previous Marijuana:

Current Marijuana:

Previous Opiates:

Current Opiates:

Past Medical History (Select all that apply):

Cardiac or Hypertension

Explain:

Diabetes

Explain:

Respiratory

Explain:

Head Injuries

Explain:

Previous DTs / Withdrawal Problems

Explain:

Seizures

Explain:

Other

Explain:

Past Psychiatric History - Have you ever experienced any problems with:

Depression:

Bipolar:

Suicide attempts:

Hospitalization for psychiatric care:

Acted violently toward others:

Notes:

Current medications and dosages:

Allergies to medication:

4 of 5 - FAMILY HISTORY

Mother Age (if alive):

Medical problems:

If deceased, age at time of death:

Cause of death:

Alcoholism or Substance Abuse:

Father Age (if alive):

Medical problems:

If deceased, age at time of death:

Cause of death:

Alcoholism or Substance Abuse:

Other family history of Substance Abuse or Alcoholism:

5 of 5 - SOCIAL HISTORY

Marital status

For how long:

Children (listed ages):

Lives with:

Other alcohol or drug use in the home:

Most recent time of employment (list year):

Type of work:

Pregnant:

Date of LMP:

Using birth control:

Please Initial:

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

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Rapid Benzodiazepine Detox Screening Form