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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