Intake

Based on several new patient encounters over the last few weeks, I’m making an intake form for all new patients requesting narcotics.  It will look something like this:

1.   Are you taking cocaine right now?

2.   No? Good. Okay.

3.   Why have you fired your last 3 doctors or been fired from their practice?

4.   Are you expecting narcotics today, as in, right now?

5.   Because I am not going to give them to you without a little more information.

6.   What exactly is your pain?

7.   What, besides Vicodin, are you doing for your pain?

8.   Ok, what, besides medications, are you doing for your pain?

9.   Are you taking methamphetamine right now?

10. No? Good. Okay.

11. Are you willing to submit to a drug test?

12. Why aren’t you able to pee today?

13. If you had to choose among the Percocet, the Xanax, and the Soma you currently want to take all at once, which would you pick?

14a. Is it cool if I call your previous doctor before our next visit?

14b. Please list the names of the doctors you have received prescriptions from in the last 2 months:

1)_________________________

2)_________________________

3)_________________________

4)_________________________

5)_________________________

6)_________________________

15. Many people seem to have nicknames for their medications. What do you like to call your pain pills? (e.g. oxies, vikes, etc.)

16. After leaving jail last month and having been off narcotics for a year, why did you then immediately resume taking 8 oxycodone 30’s a day? Are you sure you’re taking them? Because you do not appear to be dead.

17. In the past month, how many times has your cat knocked your Vicodin into the toilet? (0-5) (5-10) (>10)

18. In the past month, how many times has your cat knocked your Ciprofloxacin into the toilet? (For statistical purposes only)

It will be printed on pleasing pink paper with a marbled background and smell like candy canes.  I’m super excited.