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Current Medication
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Treatment Duration
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Daily Dose
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Have you used alochol since the last visit?
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Have you relapsed since last visit?
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Taking medication as prescribed?
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How long since your last dose?
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Are you satisfied with the treatment you are receiving?
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Are you experiencing cravings or withdrawal?
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Are you experiencing any side effects?
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USD Appropriate?
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Pharmacy Name
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Name of Doctor you will be meeting today
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Is pregnant
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Number of weeks pregnant
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Counseling since last visit?
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Date of Last Counseling:
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Counselor:
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Case management since last visit?
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Date of Last Case Management:
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Patient Weight
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Patient Height
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Patient Temperature
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Patient BP
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Prior Authorization required?
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