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Inland Family Practice Center, LLC

Quality Health Care for the Whole Family

Suboxone Intake Questionnaire

Ikechukwu Okorie, MD
423 Weathersby Rd, Suite 200
Hattiesburg, MS 39402
601-544-7012

A. Personal Information
Full Name
Date of Birth:
Contact Information
Phone
Email
Address
Insurance Information (if applicable):
B. Substance Use History
Opioid Use:
Which opioids have you used? (e.g., oxycodone, heroin, prescription painkillers)
When did you first start using opioids?
Current frequency and amount used (e.g., number of pills, daily cost)
When was your last opioid use?
Previous Treatment Attempts:
Have you ever received treatment for opioid dependency (e.g., methadone, buprenorphine/Suboxone, rehab programs)?
If yes, please describe the treatment(s) and outcomes:
Other Substance Use:
Have you used any other substances (e.g., cocaine, benzodiazepines, alcohol)?
If yes, list the substances and frequency of use:
C. Current Symptoms & Withdrawal
1. Withdrawal Symptoms: (Check all that apply)

Craving Assessment:

On a scale of 1–10, how intense are your cravings right now?

3. Self-Management:

What strategies have you used in the past to manage withdrawal or cravings?

D. Medical & Psychiatric History
Current Medications:

List any medications you are taking:

Medical Conditions:

Do you have any chronic conditions? (e.g., diabetes, liver disease)

Psychiatric History:

Have you been diagnosed with any mental health conditions (e.g., depression, anxiety)?
If yes, please list and describe:

E. Social & Legal History
1. Employment Status:

Current employment status:

2. Living Situation:

Please describe your current housing and support system:

3. Legal Involvement:

Have you had any legal issues related to substance use (e.g., DUI, court-mandated treatment)?
If yes, please provide details:

F. Treatment Goals & Expectations

1. Motivation for Treatment:

What are your goals in starting Suboxone treatment?

Expectations

What do you hope to achieve with this treatment?

Additional Support:

Are you interested in counseling or support groups as part of your recovery?

G. Consent & Acknowledgment

I understand the benefits and risks of Suboxone treatment and agree to participate in this
treatment program.

Date

Contact Us

Please feel free to contact us we will get back to you as soon as possible.

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