Pre-Transplant Chemical Dependency evaluation form using



Pre-Transplant Chemical Disorder evaluation form usingStandard CriteriaPatient Name: FORMTEXT ?????Institution: FORMTEXT ?????Date of Birth: FORMTEXT ?????Gender: FORMTEXT ?????Race: FORMTEXT ?????CD Diagnosis: FORMTEXT ?????CD Evaluation Date: FORMTEXT ?????Level of Severity:Mild (2-3): FORMCHECKBOX Moderate (4-5): FORMCHECKBOX Severe (6+): FORMCHECKBOX 1)Length of abstinence prior to CDE:Months AbstinentAlcohol FORMTEXT ?????Drugs* (specify) FORMTEXT ????? FORMTEXT ?????Confirmed by (check all that apply):Patient FORMCHECKBOX Collateral FORMCHECKBOX Lab FORMCHECKBOX 2)Length of abstinence at time of OSOTC patient review:Months AbstinentAlcohol FORMTEXT ?????Drugs* (specify) FORMTEXT ????? FORMTEXT ?????3)Active participation in an ongoing structured CD treatment program:YesNoPrior to CD Evaluation FORMCHECKBOX FORMCHECKBOX Recommended after CDE but pre-transplant FORMCHECKBOX FORMCHECKBOX 4)Active 12-Step meeting attendance (AA/NA/CA):Prior to CD Evaluation FORMCHECKBOX FORMCHECKBOX Recommended after CDE but pre-transplant FORMCHECKBOX FORMCHECKBOX Sponsor selection with ongoing contact FORMCHECKBOX FORMCHECKBOX 5)Stable sober support system FORMCHECKBOX FORMCHECKBOX 6)Contract to continue abstinence and active recovery program post-transplant FORMCHECKBOX FORMCHECKBOX 7)Negative random toxicology screens since (enter date) FORMTEXT ?????Number of screens performed since this date: FORMTEXT ?????8)Patient meets OSOTC Standard CD Criteria FORMCHECKBOX FORMCHECKBOX *includes stimulants/cocaine, marijuana, sedatives/hypnotics, hallucinogensIf your patient does not meet the Standard Chemical Disorder Criteria, but may qualify for listing under the Medically Urgent Criteria, please use the Medically Urgent pleted by: FORMTEXT ????? ................
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