SOAPP Form

Screener an Opiod Assessment for Patients with Pain - SOAPP V1-14Q

The following are some questions given to all patients who are on or being considered for medication for their pain. Please answer each question as honestly as possible. There are no right or wrong answers.

How often do you have mood swings?(Required)

How often do you smoke a cigarette within an hour after you wake up?(Required)

How often have any of your family members, including parents and grandparents, had a problem with alcohol or drugs?(Required)

How often have any of your close friends suggested that you have a drug or alcohol problem?(Required)

How often is there tension in the home?(Required)

How often have you attended an AA or NA meeting?(Required)

How often have you taken medication other than the way it was prescribed?(Required)

How often have you been treated for an alcohol or drug problem?(Required)

How often have your medications been lost or stolen?(Required)

How often have others expressed concern over your use of medication?(Required)

How often have you felt a craving for medication?(Required)

How often have you been asked to give a urine screen for substance abuse?(Required)

How often have you used illegal drugs (example marijuana, cocaine, etc) in the past five years?(Required)

How often, in your lifetime, have you had legal problems or been arrested?(Required)

Please include any additional information you wish about the above answers.

SOAPP Form

SOAPP

Screener an Opiod Assessment for Patients with Pain - SOAPP V1-14Q

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