Form #6



Form #6-2019

Piedmont Psychiatric Clinic

Patients’ Name: _______________________________ Date: _________________

Instructions: Please check any of the following you have ever used, tried or have been prescribed:

|□ |Adderall | | | |"Recreational" Drugs |

|□ |Ambien or other sleeping | |□ |Suboxone |□ |Alcohol |

| |pills | | | | | |

|□ |Amphetamine | |□ |Subutex |□ |Angel Dust |

|□ |Codeine | |□ |Sufentanil |□ |Bath Salts (Synthetic Cathinones) |

|□ |Concerta | |□ |Talwin |□ |Blue Nitro |

|□ |Cylert | |□ |Tussi- Organidin |□ |Cocaine |

|□ |Darvocet | |□ |Tussionex |□ |Crack |

|□ |Darvon | |□ |Vyvanse |□ |Crank |

|□ |Daytrana | |□ |Kratom |□ |Ecstasy |

|□ |Demerol | | | |□ |GHB |

|□ |Dexedrine | | | |□ |Glue or Gasoline Sniffing |

|□ |Dextroamphetamine | |Benzodiazepines |□ |Heroin |

|□ |Dilaudid | |□ |Ativan (lorazepam) |□ |Inhalants |

|□ |Fentanyl | |□ |Klonopin (Clonazepam) |□ |K/2/Spice (Synthetic Marijuana) |

|□ |Firocet | |□ |Librium (chlordiazepoxide) |□ |Ketamines |

|□ |Hycodan | |□ |Tranxene (clorazepate) |□ |LSD |

|□ |Hydrocodone | |□ |Valium (diazepam) |□ |Marijuana |

|□ |Lorcet | |□ |Xanax (alprazolam) |□ |MDMA (Molly) |

|□ |Lortab | | | |□ |Methamphetamine (Crystal Meth | Ice) |

|□ |Methadone | | | |□ |Mushrooms (Psyilocybin) |

|□ |Morphine | |Tobacco | |□ |PCP |

|□ |Naltrexone | |□ |Chewing |□ |Peyote |

|□ |Norco | |□ |Cigarettes |□ |Ripped Fuel |

|□ |Oxycodone | |□ |Cigars |□ |Rohypnol (Roofies) |

|□ |Oxycontin | |□ |Snuff |□ |Speed |

|□ |Oxymorphone | | | |□ |Steroid Supplements |

|□ |Percocet | |Other |  |□ |Stimulants Drinks I.e.: Red Bull |

|□ |Percodan | |□ |  |□ |Weight Loss Supplements |

|□ |Provigil | |□ |  | | |

|□ |Ritalin | |□ |  | | |

|□ |Roxycontin | | | | | |

| | | | | | | |

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