HTML Preview Quality Care Therapy Progress Report page number 1.
QUALITY CARE
THERAPY PROGRESS REPORT
(Adapted from Subjective Opiate Withdrawal Scale)
Instructions:
- Patient fills out “COMPLETED BY PATIENT” section and brings form to counselor
- Counselor fills out and signs “COMPLETED BY COUNSELOR” section and returns form to patient
- Patient brings form to physician. Physician fills out “COMPLETED BY PHYSICIAN” section and files with patient records
Patient Name
Medication dose mg/day Date
COMPLETED BY PATIENT
Circle the answer that best fits the way you feel now
Not all all Extremely
I feel anxious 0 1 2 3 4
I feel like yawning 0 1 2 3 4
I am perspiring 0 1 2 3 4
My nose is running and/or my eyes are watery 0 1 2 3 4
I have goosebumps and/or chills 0 1 2 3 4
I feel nauseated or like I may need to vomit 0 1 2 3 4
I have stomach cramps and/or diarrhea 0 1 2 3 4
My muscles twitch 0 1 2 3 4
I feel dehydrated and/or have not had much appetite 0 1 2 3 4
I am having difficulty sleeping 0 1 2 3 4
I have a headache 0 1 2 3 4
My muscles and bones ache 0 1 2 3 4
I feel like using right now 0 1 2 3 4
I would rate my overall level of withdrawal as 0 1 2 3 4
Do you feel you need a dosage change?
No Yes Up Down
Have you used alcohol or other drugs since your last visit?
No Yes
If “yes,” please describe what, when, and how much
Handelsman L, Cochrane KJ, Aronson MJ, Ness R, Rubinstein KJ, Kanof PD. (1987). Two new rating scales for opiate withdrawal. Am J Drug Alcohol Abuse. 13(3):293-308.
Reprinted by permission of the publisher (Taylor & Francis Ltd, http://www.tandf.co.uk/journals).
Please describe any life changes, triggers, or stressors that have occurred since your last visit.