Methadone Encounter

CPSO Methadone Encounter

Patient Name:
Date:
Current Methadone Dose:
Number of Take-Home Doses:
Missed doses:
Supervised UDS:
EDDP:
Cocaine
Opiates:
Benzodiazepines:
Oxycodone:
Buprenorphine
Creatinine
pH
Interpretation
Patient stated drug/alcohol use and route Since Last visit:
Opiates:
Cocaine:
Benzodiazepines:
Alcohol:
Other problematic drug use:
Opiod Cravings None Mild Moderate Severe Opiod Withdrawal None Mild Moderate Severe
Opioid Withdrawl Symptoms
None Insomnia Anxiety Dysphoria Nausea Diarrhea Hot Flashes Irritablility Myalgia Restlessness Rhinorrhea Sneezing Sweats Yawning Pupil Dilated Malaise Abdominal Cramping Piloerection
Timing of Withdrawl from Last Dose:

Psychological Issues Update:
Mood:	Normal Other
Sleep:	Normal Insomnia
Anxiety:	Absent Present
Energy:	Normal Other
Suicidal ideation:	Absent Present Not Assessed
O/E:
Appearance:	Alert Intoxicated
Behaviour:	Normal Abnormal
Gait:	Normal Abnormal
Speech:	Normal Abnormal
Eye Contact:	Normal Abnormal
Reported methadone Sedation:
Reported methadone withdrawal:
Take-home dose safety issues discussed:	Yes No NA
Reviewed Dangers of methadone diversion:	Yes No NA
Clinically Stable:	Yes No
Take-home doses locked in a box:	Yes No NA
Safe with take-home doses:	Yes No
Stable housing:	Yes No
Stable employment/ social support:	Yes No
Reported methadone withdrawal:	Yes No

Counselling/Clinical Notes

Plan|
Rx: Methadone mg po od from to
Number Carries Take-home doses: Sun Mon Tue Wed Thur Fri Sat
Next visit in days

Subject: