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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