Addiction Medicine Initial Evaluation (Biopsychosocial & Diagnostic)

Date/Time: [Date and time of encounter]

Setting: [clinic / ED / inpatient]

Visit Type: Initial Evaluation

Clinician: [Name, credentials]

Referral Source: [self-referred / primary care / hospital discharge / court/probation / other: specify]

Interpreter: [yes / no; language if yes]

Information Sources Reviewed: [Patient report / PDMP / outside records / labs / collateral contacts—specify which and date accessed]

Confidentiality and Consents: [SUD-specific confidentiality status; releases of information obtained today with recipient, purpose, and expiration; disclosure restrictions]

Chief Concern

[Patient-stated concern in their own words]

History of Present Illness

[Why seeking care now; precipitating events; current substance use snapshot for priority substances including route, frequency, amount, last use; intoxication or withdrawal state; immediate safety concerns; patient goals and readiness; brief note on prior treatment response] (Narrative, 1–3 paragraphs. Label information sources for key facts.)

• Primary substances: [For each primary/urgent substance: substance, route, amount, frequency, last use]
• Current clinical state: [Intoxication and/or withdrawal symptoms, severity, onset]
• Immediate safety concerns: [Overdose risk, suicidality, inability to care for self, medical red flags]
• Patient goals/readiness: [Stated goals, stage of change]
• Prior treatment response: [Approaches that helped, barriers encountered]

Substance Use History

Global overview: [Age at first use; escalation milestones; polysubstance pattern; longest abstinence and supports; overdose history summary]

Summary of current use and risks:

• [Substance] — Current: [yes / no]; Route: [route]; Frequency: [frequency]; Last use: [date/time]; Withdrawal risk: [low / moderate / high]; Overdose risk: [low / moderate / high]
• (Repeat for each relevant substance: opioids, alcohol, benzodiazepines, stimulants, cannabis, nicotine, others.)

Substance-specific details: (Include for each substance requiring detailed documentation.)

• [Substance name]
  • Pattern: [Age first used, progression, current use status, typical amount/frequency/route]
  • Last use and recent timeline: [Date/time of last use, recent use pattern]
  • Withdrawal history: [Symptoms experienced, complications such as seizures or DTs, severity]
  • Consequences: [Medical, psychiatric, social, legal, occupational, financial, infectious risk behaviors]
  • Diagnostic basis: [DSM criterion clusters met with 1–2 concrete examples supporting diagnosis and severity] (Do not assign severity without documented criteria.)
  • Prior treatment: [Medications tried with response/side effects, behavioral treatments]
  • Patient goals: [Abstinence, reduction, safer use, medication preferences]

Prior SUD Treatment and Recovery Supports

• Treatment episodes: [Detox, residential, IOP/PHP, outpatient, OTP, sober living, incarceration-based—include dates, duration, outcomes]
• Medications for SUD: [Medication, dose, duration, benefit, adverse effects, reason discontinued or current status] (Include MOUD, alcohol pharmacotherapy, nicotine pharmacotherapy.)
• Psychosocial supports: [Counseling type, peer recovery, mutual-help involvement, family involvement]
• Barriers and facilitators: [Transportation, housing, work, childcare, legal, motivation, supportive relationships]

Psychiatric History

• Diagnoses: [Depression, anxiety, PTSD, bipolar, psychosis, ADHD, personality features] (Specify confirmed vs provisional.)
• Treatment history: [Therapies, hospitalizations, medication trials with responses]
• Safety history: [Suicide attempts, self-harm, violence, prior ED visits for safety—include dates and context]
• Trauma history: [Clinically relevant summary] (Document in trauma-informed manner; avoid gratuitous detail.)
• Current symptoms: [Mood, anxiety, sleep, appetite, psychotic symptoms, cognition]

Medical History

• Active medical problems: [Current diagnoses and relevant past history]
• Pain history: [Location, functional impact, treatments, opioid exposure context] (Include if applicable.)
• Infectious disease: [HIV status and testing history, hepatitis B/C status and testing, injection-related infections, TB risk]
• Reproductive health: [Pregnancy status, contraception, perinatal considerations] (Include when applicable.)
• Current medications: [Name, dose, frequency, indication, adherence]
• Allergies: [Allergen, reaction type, severity]

Social History and Recovery Environment

• Housing: [Type, stability, substance exposure in home, safety concerns]
• Family and relationships: [Supports, dependents, caregiving responsibilities]
• Employment/education/finances: [Status, stability, functional impact]
• Legal involvement: [Probation, parole, court mandates, pending charges]
• Transportation and technology access: [Availability, barriers]
• IPV screening: [Screening result, actions if positive]
• Strengths and protective factors: [Motivation, supportive relationships, employment stability, spirituality, engagement]

Family History

• [Substance use disorders in first-degree relatives]
• [Mental illness]
• [Suicide or suicide attempts]
• [Relevant medical conditions]

Review of Systems

(Include only when medically appropriate. Target systems relevant to withdrawal risk, medication safety, infectious concerns, pregnancy, or acute complaints.)

• [Targeted positive and pertinent negative findings]

Objective Data

Vitals

BP: [value] | HR: [value] | RR: [value] | Temp: [value] | SpO2: [value] | Weight: [value]

[Pertinent findings related to intoxication or withdrawal] (Include only if applicable.)

Physical Examination

(Document only what was performed. If no exam performed, state reason.)

• General: [Appearance, level of distress]
• Signs of intoxication/withdrawal: [Pupils, diaphoresis, tremor, agitation, other]
• Skin: [Injection sites, track marks, abscesses, rashes]
• Cardiopulmonary: [Findings]
• Neurologic: [Mental status, focal deficits, tremor, gait]
• Other: [Additional findings as applicable]

Mental Status Examination

• Appearance/behavior: [Findings]
• Speech: [Rate, rhythm, volume, tone]
• Mood/affect: [Stated mood, observed affect]
• Thought process/content: [Organization, themes, SI/HI]
• Perception: [Hallucinations, illusions]
• Cognition: [Orientation, attention, memory]
• Insight/judgment: [Assessment]
• Reliability: [good / fair / poor] (Note impact of intoxication, withdrawal, or cognitive impairment.)

Data Reviewed

• PDMP: [Key controlled substances, dates, prescribers, discrepancies—include date accessed]
• Toxicology: [Specimen type, POC vs lab, presumptive vs confirmatory, results, interpretation with limitations]
• Labs: [CBC, CMP, LFTs, pregnancy test, hepatitis/HIV, other—include dates]
• Outside records: [Pertinent findings with sources specified]

Risk Assessment

Overdose Risk

• Prior overdoses: [Number, timing, circumstances, naloxone used]
• Naloxone status: [Current access: yes / no; training status; provided today: yes / no]
• Tolerance factors: [Current opioid tolerance, recent abstinence periods]
• Polysubstance use: [Concurrent depressants: alcohol, benzodiazepines, others]
• High-risk factors: [Using alone, unstable housing, recent incarceration or hospitalization, fentanyl exposure]
• Harm reduction today: [Overdose education provided, naloxone dispensed, safer use counseling]
• Risk level: [low / moderate / high] — [Rationale]

Withdrawal Risk

• Alcohol/benzodiazepines/barbiturates: [Daily use level, last use, prior complicated withdrawal including seizures or DTs, expected onset]
• Opioids: [Withdrawal severity, validated scale score if used, timing relative to last use]
• Disposition rationale: [Ambulatory vs higher level of care—rationale and contingency plan]
• Risk level: [low / moderate / high] — [Rationale]

Suicide and Self-Harm Risk

• Screening: [negative / positive] (Specify tool if used.)
• Assessment if positive: [Ideation, plan, intent, means access, past attempts, precipitants, protective factors]
• Risk level: [low / moderate / high] — [Rationale]
• Safety actions: [Safety plan, crisis resources provided, means restriction counseling, disposition decision]
• Violence risk: [Assessment and actions] (Include only if clinically indicated.)

Assessment

Diagnostic Formulation

• Substance-related diagnoses: [Substance, severity, status: active vs in remission] — Evidence: [Criterion clusters met with examples] (Note uncertainty if features may be substance-induced; document plan for reassessment.)
• Co-occurring psychiatric diagnoses: [Diagnosis, confirmed vs provisional, substance-induced vs primary] (Note temporal relationship to intoxication/withdrawal.)
• Medical diagnoses affecting treatment: [Relevant conditions]
• Psychosocial factors: [Social determinants and contextual factors impacting care]

Multidimensional Severity Summary

• Intoxication/Withdrawal: [Severity, key facts, implications for care]
• Biomedical Conditions: [Severity, key facts, implications for care]
• Emotional/Behavioral/Cognitive: [Severity, key facts, implications for care]
• Readiness to Change: [Severity, key facts, implications for care]
• Relapse/Continued Use Potential: [Severity, key facts, implications for care]
• Recovery Environment: [Severity, key facts, implications for care]
• Recommended level of care: [Outpatient / IOP/PHP / Residential / Inpatient / ED transfer] — [Rationale, patient preference, shared decision-making outcome] (If patient declines recommendation, document capacity assessment, counseling provided, and mitigation plan.)

Plan

(Organize by problem, aligned with Assessment.)

• Treatment setting: [Outpatient / IOP/PHP / Residential / Inpatient] — [Rationale]
• Pharmacotherapy: [Medication selected, rationale, contraindications considered, baseline data needed, induction/starting plan, monitoring plan] (If not started today, document reason.)
• Psychosocial interventions: [Counseling referrals, peer support linkage, mutual-help, family involvement]
• Harm reduction: [Naloxone prescribed and training provided, overdose education, safer use counseling, syringe services linkage]
• Withdrawal management: [Outpatient instructions, symptom management, return precautions for escalation]
• Co-occurring psychiatric care: [Medication changes, therapy referrals, safety plan]
• Medical care: [Infectious disease screening/referrals, vaccinations, primary care coordination, wound care]
• Social supports: [Housing, food, transportation, insurance, legal, DV resources as indicated]
• Monitoring: [Follow-up interval, urine drug testing strategy with clinical purpose, PDMP check schedule, labs to trend]
• Patient education: [Risks/benefits/alternatives discussed, questions answered, informed consent]

Disposition and Follow-Up

• Disposition: [Home / ED / Inpatient] — [Transportation plan if transfer]
• Follow-up: [Date or timeframe, focus for next visit]
• Return precautions: [Overdose symptoms, severe withdrawal, suicidality, chest pain, confusion, other red flags]
• Care coordination: [Referrals placed, communications sent, consent status]