Mark Each Box That Applies Female Male
Family History of Alcohol Abuse
Family History of Illegal Drug Abuse
Family History of Rx Drug Abuse
Personal History of Alcohol Abuse
Personal History of Illegal Drug Abuse
Personal History of Rx Drug Abuse
Age Between 16-45 Years
History of Preadolescent Sexual Abuse
ADD, OCD, bipolar, schizophrenia
Depression
Total Score:

Low Risk

Annual Pain Assessment
Substance Abuse assessment
Informed consent for opioid use
Signed treatment agreement
Regular follow up visits
Initial and annual pharmacy database review
Obtain previous medical records
Initial and annual urine drug screen
No consultation required
Document patient-provider interactions
Other treatments and/or self-management documented
Annual re-screening for opioid risk status
Other treatments and/or self-management documented

Webster LR, Webster R. Predicting aberrant behaviors in Opioid-treated patients: preliminary validation of the Opioid risk tool. Pain Med. 2005;6(6):432