| Intake Question
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| Referral Source
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| Are you currently on active duty?
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| Military Branch
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| Highest Level of Education
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| Employment status
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| Are you currently enrolled in school or job training program?
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| Are you currently enrolled in school or job training program?
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| Are you currently using?
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| Routine of administration types:
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| During the past 30 days, how many days have you used any of the following:
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| Cocaine/crack
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| Marijuana/Hashish
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| Heroine
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| Morphine
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| Dilaudid
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| Demerol
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| Fentanyl
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| Percocet
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| Darvon
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| Codeine
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| Tylenol 2, 3, 4
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| OxyContin/Oxycodone
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| Non-prescription methadone
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| Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline
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| Methamphetamine or other amphetamines
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| During the past 30 days, how many days have you used any of the following:
|
| Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam
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| Barbiturates: Metharbital and pentobarbital sodium
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| Non-prescription GHB
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| Ketamine
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| Other tranquilizers, downers sedatives, or hypnotic
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| Inhalants
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| Other illegal drugs
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| Drug of Choice-Diagnosis
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| Behavioral Health
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| Children's Services Referral
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| If Children's Services referral, do you have an active Children's Services case?
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| # of children that you have
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| # of children that you have
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| Crime Justus status
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| Probation
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| Parole
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| PROB 45
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| Human Trafficking
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| Is there a history of Sexual Abuse?
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| Program Placement (Level of Care)
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| Sober Housing Needed
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| Sober Housing Provided
|
|
|
|
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| Medical Intake Questions
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| If female, are you pregnant?
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| Medicated Assisted Treatment (MAT)
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| Hypertension
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| Diabetes
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| STI's
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| UTI's
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| Cellulitis
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| COPD
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| Asthma
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| Blood dyscrasia
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| City
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| State
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| Zip code
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| County
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| Is there a history of drug use?
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| In the past 30 days, where have you been living most of the time?
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| Are you currently employed?
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