Quality Care Therapy Progress Report
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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 Have you used alcohol or other drugs since your last visit No Yes Up Down If “yes,” please describe what, when, and how much Handelsman L, Cochrane KJ, Aronson MJ, Ness R, Rubinstein KJ, Kanof PD..
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