q Scott Balogh, MD, FASAM, ABAM, ABPN
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
q Other: ____________________________________
Patient Information
Name: ________________________________________________________________________________ Sex: Male _____ Female _____
Social Security #: _________________________________________________ Date of birth: _____________________________________
Address: ______________________________________________ City: ________________________ State: ______ ZIP: ______________
E-mail: _______________________________________________________________________ Marital status: __________________________
Phone: _________________________________________________________ Cell: __________________________________________________
Employer Information
Employer: _____________________________________________________________________ Work phone _________________________
Spouse Information (or responsible party info if different from the patient)
Name: ______________________________________________________________________ Social Security #: _______________________
Employer & address: __________________________________________________________________________________________________
Phone: ______________________________________________________________ Date of birth: __________________________________
Emergency Contact
Name: __________________________________________________________________________ Relationship: _______________________
Address: ______________________________________________ City: ________________________ State: ______ ZIP: ______________
Phone: _________________________________________________________ Cell: __________________________________________________
Insurance Information (copy of insurance card or cards)
Primary insurance: _____________________________________ Policy #: _____________________ Group #: _____________________
Policy holder name: ____________________________________________________ Policy holder DOB: ___________________________
Policy holder SSN: ___________________________________________ Relationship to patient: ________________________________
_
I authorize you to release my medical information on myself for referrals. I authorize the releae of any medical
information needed to process insurance claims. I further authorize payment of medical benefits to the physician in
the event they file for insurance. I understand that I am completely responsible for all charges.
Patient signature ________________________________________________________________________ Date ________________________
Do you have a living will?
Yes _____ No _____
q Scott Balogh, MD, FASAM, ABAM, ABPN
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Other: ____________________________________
Patient Intake: Medical History (To be completed by the patient.)
Name: ________________________________________________________________________________________________________________
Address: ______________________________________________ City: ________________________ State: ______ ZIP: ______________
Phone: ________________________________ Work: _________________________________ Cell: __________________________________
Date of birth: _____________________________________ Age: ________________ SS#: _________________________________________
Emergency contact: ___________________________________________________________________________________________________
Relationship to patient: ___________________________________________________ Phone: ____________________________________
Primary care physician: ___________________________________________________ Phone: ____________________________________
Last date of physical: _______________________ Have you ever had an EKG?
Yes _____ No _____ Date: __________________
Current or past medical conditions (check all that apply.)
❒ Asthma / respiratory
❒ Cardiovascular (heart attack, high cholesterol, angina
❒ Hypertension
❒ Epilepsy or sezure disorder
❒ GI disease
❒ Head trauma
❒ HIV / AIDS
❒ Diabetes
❒ Liver problems
❒ Pancreatic problems
❒ Thyroid disease
❒ STDs
❒ Abnormal pap smear
❒ Nutritional deficiency
Other (Please describe): _______________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
If there is family history of any of the illnesses listed above, please put an “F” next to that illness.
MD NOTES: ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Is there is family history of any of anything NOT listed here? (Please explain): ________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
MD NOTES: ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Childhood Illnesses
Measles: ❒ Yes ❒ No
Mumps: ❒ Yes ❒ No
Chicken Pox: ❒ Yes ❒ No
Have you or a family member ever been diagnosed with a psychiatric or mental illness? (Please describe): ___________
________________________________________________________________________________________________________________________
Have you ever taken or been prescribed antidepressants? ❒ Yes ❒ No, If yes, for what reason?: ____________________
Medication(s) and date of use: ___________________________ Why stopped: ______________________________________________
Please list all current prescription medicationsand how often you take them (example: Dilantin 3x/day).
Page 2
DO NOT include medications you may be currently misusing (that information is needed later): _____________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Please list all current herbal medicines, vitamin supplements, etc. and how often you take them: ____________________
________________________________________________________________________________________________________________________
MD NOTES: ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Please list any allergies you have (penicillin, bees, peanuts): __________________________________________________________
________________________________________________________________________________________________________________________
MD NOTES: ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Tobacco History
Cigarettes: Now? ❒ Yes ❒ No In the past? ❒ Yes ❒ No Packs per day? ___________ How many years? ___________
Pipe: Now? ❒ Yes ❒ No In the past? ❒ Yes ❒ No
How often a day? ___________ How many years? ___________
Have you ever been treated for substance misuse? ❒ Yes ❒ No (Please describe when, where and for how long?)
________________________________________________________________________________________________________________________
How long have you been using substnaces? __________________________________________________________________________
Substance Abuse History
No
Alcohol
Caffeine (pills
or beverages)
Cocaine
Crystal MethAmphetamine
Heroin
Inhalants
LSD or
Hallucinogens
Marijuana
Methadone
Pain Killers
PCP
Stimulants (pills)
Tranquilizers /
Sleeping Pills
Ecstacy
Other
Yes/Past
Route
How much? How often?
Date/Time
or Yes/Now
Quantity
last used
Did you ever stop using any of the above because of dependence? ❒ Yes ❒ No (Please list):
Page 3
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
What was your longest period of abstinance? _________________________________________________________________________
________________________________________________________________________________________________________________________
MD NOTES: ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
q Scott Balogh, MD, FASAM, ABAM, ABPN
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Other: ____________________________________
Pretreatment Screening Call Date: ___________________________ Call Time: ___________________________
Name: ________________________________________________________________________________________________________________
Phone: _________________________________________________ Best time to contact: _________________________________________
Address: ______________________________________________ City: ________________________ State: ______ ZIP: ______________
Date of birth: ____________________________________________________ Age: ________________ Sex:
Male _____ Female _____
Insurance company: ___________________________________________________ Insurance member #: ________________________
Do you plan to submit a claim?
Yes _____ No _____
Reason for seeking treatment
Substance: ___________________________________________________ How long using? ____________________________________
How much? ___________________________________________________ How often? ____________________________________
Has your drug use ever resulted in medical or legal problems?
Yes _____ No _____ If yes, explain: __________________
Have you ever been treated fro substance dependence or misuse (eg, detoxification program)?
Yes _____ No _____
(Please describe setting and length.) __________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Have you ever tried to quit on your own?
Yes _____ No _____ (Please decribe) ______________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Have you ever been treated by a psychiatrist?
Yes _____ No _____ (Please decribe treatment reason, setting, and length)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Does anyone in your family (mother, father, brother/sister, child, aunt/uncle or grandparent) have a history of
substance abuse?
Yes _____ No _____ (Please explain) ______________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
ACM - 4/16
page 1 of 2
Page 2
Do you have any medical conditions (diabetes, HIV, epilepsy, STDs?
Yes _____ No _____ (Please decribe) ___________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Are you currently taking any medications to treat these conditions?
Yes _____ No _____ (List medication and dosage)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Are you pregnant?
Yes _____ No _____ N/A _____ Not sure _____
Are there any current legal issues we should be aware of (probation, parole)?
Yes _____ No _____ (Please explain)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Are you currently employed?
Yes _____ No _____ How many hours do you work in a week on average? ____________
________________________________________________________________________________________________________________________
Please describe your current living arrangements: ____________________________________________________________________
________________________________________________________________________________________________________________________
Other: _________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Patient Interviewer Signature: ___________________________________________________ Date: _______________________________
ACM - 4/16
page 2 of 2
q Scott Balogh, MD, FASAM, ABAM, ABPN
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Other: ____________________________________
Patient name: _____________________________________________________________________________________________
ALLERGIC:
Problem
Date
ACM - 4/16
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
Onset
Medications
Resolved
Adult Tetanus Toxoid
Review of Systems
1407 Union Avenue, Suite 700
Memphis, Tennessee 38104-3641
901-866-8864
Please answer ALL questions.
Have you experienced any of the following in the last 6 months?
CONSTITUTIONAL
Good general health lately........................................ No
Recent weight change .............................................. No
Fever ........................................................................ No
Fatigue...................................................................... No
Headaches ............................................................... No
Yes
Yes
Yes
Yes
Yes
EYES
Eye disease or injury ................................................ No
Wear glasses/contact lens ....................................... No
Blurred or double vision ........................................... No
Glaucoma ................................................................ No
Yes
Yes
Yes
Yes
ENT
Hearing loss ............................................................. No
Ringing in the ears ................................................... No
Earaches or drainage .............................................. No
Sinus problems ........................................................ No
Nose bleeds ............................................................. No
Mouth sores ............................................................. No
Bleeding gums ......................................................... No
Bad breath or bad taste ........................................... No
Sore throat or voice change .................................... No
Swollen glands in neck ............................................ No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
CARDIOVASCULAR
Heart trouble ............................................................ No
Chest pains .............................................................. No
Sudden heart beat changes .................................... No
Swelling of feet, ankles or hands ............................. No
Yes
Yes
Yes
Yes
RESPIRATORY
Frequent coughing ................................................... No
Spitting up blood ...................................................... No
Shortness of breath ................................................. No
Asthma or wheezing ................................................ No
Yes
Yes
Yes
Yes
GASTROINTESTINAL
Loss of appetite ....................................................... No
Change in bowel movements .................................. No
Nausea or vomiting .................................................. No
Frequent diarrhea .................................................... No
Painful bowel movements or constipation ............... No
Blood in stool ........................................................... No
Stomach pain ........................................................... No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
GENITOURINARY
Frequent urination ................................................... No
Yes
Burning or painful urination ...................................... No
Yes
Blood in urine ........................................................... No
Yes
Change of force of strain when urinating ................. No
Yes
Incontinence or dribbling ......................................... No
Yes
Kidney stones .......................................................... No
Yes
Male - testicle pain ................................................... No
Yes
Female - pain with periods ...................................... No
Yes
Female - irregular periods ....................................... No
Yes
Female - vaginal discharge ..................................... No
Yes
Female - # pregnancies _______ # miscarriages _______
Female - date of last pap smear __________________________
Female - findings of last pap smear ❒ Normal ❒ Abnormal
MUSCULOSKELETAL
Joint pain ................................................................. No
Joint stiffness or swelling ......................................... No
Weakness of muscles or joints ................................ No
Muscle pain or cramps ............................................ No
Back pain ................................................................. No
Cold extremities ....................................................... No
Difficulty in walking .................................................. No
ACM - 131357 - 3/22/16
Yes
Yes
Yes
Yes
Yes
Yes
Yes
SKIN
Rash or itching ......................................................... No
Change in skin color ................................................ No
Change ill hair or nails ............................................. No
Varicose veins ......................................................... No
Breast pain .............................................................. No
Breast lump ............................................................ No
Breast discharge ...................................................... No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
NEUROLOGICAL
Frequent or recurring headaches ............................ No
Light headed or dizzy .............................................. No
Convulsions or seizures .......................................... No
Numbness or tingling sensations ............................. No
Tremors ................................................................... No
Paralysis .................................................................. No
Stroke ..................................................................... No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
PSYCHIATRIC
Memory loss or confusion ........................................ No
Nervousness ............................................................ No
Depression .............................................................. No
Sleep problems ........................................................ No
Yes
Yes
Yes
Yes
ENDOCRINE
Glandular or hormone problem ................................ No
Thyroid disease ....................................................... No
Excessive thirst or urination ..................................... No
Heat or cold intolerance ........................................... No
Dry skin .................................................................... No
Change in hat or glove size ..................................... No
Yes
Yes
Yes
Yes
Yes
Yes
HEMATOLOGIC/LYMPHATIC
Slow to heal after cuts ............................................. No
Easily bruise or bleed .............................................. No
Anemia .................................................................... No
Phlebitis ................................................................... No
Past transfusion ....................................................... No
Enlarged glands ....................................................... No
Yes
Yes
Yes
Yes
Yes
Yes
List ANY medications you are now taking.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________ ________________________
___________________________________________________________
___________________________________________________________
_______________________
_______________________________________________________
Patient Signature: ________________________________________
Provider Signature: _______________________________________
q Scott Balogh, MD, FASAM, ABAM, ABPN
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
q Other: ____________________________________
Consent to Release / Receive Confidential Information
I___________________________________________________authorize _____________________________at the above address to:
MD check all that apply
 Receive my medical history information from the following physicians:
(name,address)________________________________________________________________________________________
(name,address)________________________________________________________________________________________
 Release my treatment records from the following therapist:
Therapist (name, address)________________________________________________________________________________
 Release my treatment information/records to the following healthcare professional
(name,address)________________________________________________________________________________________
 Release my treatment information to the health insurance company list below for billing purposes
Insurance provider (name, address)________________________________________________________________________
This information is for the following purposes (any other use in prohibited): ________________________________________________
I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken in
reliance on it. This consent will last while I am being treated for opioid dependence by the physician specified above unless I withdraw
my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the physician specified about is
otherwise notified by me.
I understand that the records to be released my contain information pertaining to psychiatric treatment and/or treatment for
alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illnesses. I understand that these records are protected by the Code of Federal Regulations Title
42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties
without the express written consent of the patient.
I acknowledge that I have been notified of my right pertaining to the confidentiality of any treatment information/records under 42 CFR
Part 2, and I further acknowledge that I understand these rights.
__________________________________________________________________________________________________________
Patient SignatureDate
_________________________________________ _______________________________________________________________
Patient/Guardian SignaturePatient/Guardian Name (Print) Date
_________________________________________ _______________________________________________________________
Witness/SignatureWitness Name (Print)Date
q Scott Balogh, MD, FASAM, ABAM, ABPN
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Other: ____________________________________
Patient Treatment Contract
SUOXONE® (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet
SUBUTEX® @ (buprenorphine HCI) sublingual tablet
Patient Name Print____________________________________________________________ Date___________________________
As a participant in buprenorphine treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment
contract as follows:
1. I agree to keep and be on time to all my scheduled appointments.
2. I agree to adhere to the payment outlined by this office.
3. I agree to conduct myself in a courteous manner in the doctor’s office.
4. I agree to not sell, share, or give any of my medications to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.
5. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor’s office.
6. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the
pharmacy where my buprenorphine is filled, that the behavior will be reported to my doctor’s office and could result in my treatment being terminated without any recourse for appeal.
7. I agree that my medications/prescription can only be given to me at my regular office visits. A missed visit my result in my not
being able to get my medication/prescription until the next scheduled visit.
8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that the lost
medication will be replaced regardless of why it was lost.
9. I agree not to obtain medications from any other doctor, pharmacies, or other sources without telling my treating physician.
10. I understand that mixing buprenorphine with other medications, especially benzodiazepines (for example: Valium®, Klonopin®,
or Xanax®) can be dangerous. I also recognize that several deaths have occurred among persons mixing buprenorphine and
benzodiazepines (especially if taken outside the care of a physician, using routes of administration other than sublingual or in
higher than recommended therapeutic doses).
11. I agree to take my medications as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.
12. I understand that my medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as
discussed and agreed upon with my doctor and specified in my treatment plant.
13. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances (except nicotine).
14. I agree to provide random urine samples and have my doctor test my blood alcohol level.
15. I understand that violations as of the above may be grounds for termination of treatment.
16. Patients may be called for a pill count and check-up as anytime and will be expected to be in the office by the close of business or the day the call is made.
a. Keep your information updated each visit and cell phone on.
b. Not coming in for a pill count, UDS, check-up will be sufficient grounds to dismiss patients from the Suboxone Program.
A violation of any of the above statements of care shall constitute grounds for dismissal from the practice.
______________________________________________________________
Patient SignatureDate
Valium® is a registered trademark of Roche Products, Inc. Klonopin® is a registered trademark of Roche Laboratories, Inc. Xanax® is a registered trademark of Pharmacia & Upjohn Company
q Scott Balogh, MD, FASAM, ABAM, ABPN
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Other: ____________________________________
Appointed Pharmacy Consent
SUBOXONE® @ (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet
SUBUTEX @ (buprenorphine HCI) sublingual tablet
I______________________________________________________________________________ do hereby: (MD check all that apply)
Patient Name (Print)

Authorize_______________________________________________________________ at the above address to disclose my
Physician Name (Print)
treatment for opioid dependence to employees of the pharmacy specified below. Treatment disclosure most often includes,
but may not be limited to, discussing my medications with the pharmacist, and faxing/calling in my buprenorphine prescription
directly to the pharmacy.

Agree to allow pharmacist to contact physician listed above to discuss my treatment if necessary so that my buprenorphine prescription can be filled and either delivered to the office addressed give about or picked-up by employees of the same.
I understand that I may withdrew this consent at any time, either verbally or in writing except to the extent that action has been taken in
reliance on it. This consent will last while I am being treated for opioid dependence by the physician specified above unless I withdraw
my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the physician specified above is
otherwise notified by me.
I understand that the records to be released my contain information pertaining to psychiatric treatment and/or treatment for alcohol and/
or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or
related illnesses. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which
prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the
patients.
I acknowledge that I have been notified of my right pertaining to the confidentiality of any treatment information/records under 42 CFR
Part 2, and I further acknowledge that I understand these rights.
__________________________________________________________________________________________________________
Patient SignatureDate
_________________________________________ _______________________________________________________________
Patient/Guardian SignaturePatient/Guardian Name (Print) Date
_________________________________________ _______________________________________________________________
Witness/SignatureWitness Name (Print)Date
Appointed Pharmacy:
Name
_________________________
Phone:___________
Address ______________________________________________
q Scott Balogh, MD, FASAM, ABAM, ABPN
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Other: ____________________________________
Methadone Transfer Consent
I ____________________________________________________ authorize ______________________________________________
Patient Name (Print)
Physician Name (Print)
practicing at the above address to disclose my treatment for opioid dependence to the outpatient treatment program specified below in
order to obtain my medical history, methadone treatment, and any other of my patient information pertinent to the office based treatment
with buprenorphine. I understand that the physician mentioned above nay need to discuss my medical and treatment history with the
physicians and other staff at the outpatient treatment program specified below.
I understand that I may withdraw this consent at any time, either verbally or in writing except to the extent that action has been taken on
reliance on it. This consent will last while I am being treated for opioid dependence by the physician specified above unless I withdraw
my consent during treatment. This consent will expire 365 days after I complete my treatment, unless the physician specified above
otherwise notified by me.
I understand that the records to be released may contain information pertaining to psychiatric treatment and/ or treatment for
alcohol and/ or drug dependence. These records any also contain confidential information about communicable diseases
including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title
42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties
without the express written consent of the patient.
I acknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/ records under 42 CFR
Part 2, and I further acknowledge that I understand those rights.
__________________________________________________________________________________________________________
Patient SignatureDate
_________________________________________ _______________________________________________________________
Patient/Guardian SignaturePatient/Guardian Name (Print) Date
_________________________________________ _______________________________________________________________
Witness/SignatureWitness Name (Print)Date
Confidentiality of Alcohol and Drug Dependence Patient Records
The confidentiality of alcohol and drug dependence patient records maintained by this practice/ program is protected by federal law and
regulations. Generally, the practice/ program may not say to a person outside the practice/ program that a patient attends the practice/
program, or disclose any information identifying a patient as being alcohol or drug dependent unless:
1. The patient consents in writing.
2. The disclosure is allowed by court order, or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research audit, or practice/ program evaluation.
Violation of the federal law and regulations by a practice/ program is a crime. Suspected violations may be reported to appropriate
authorities in accordance with federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/ program or
against any person who works for the practice/ program or about any threat to commit such a crime.
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under a state
law to appropriate or state authorities.
q Scott Balogh, MD, FASAM, ABAM, ABPN
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
q Other: ____________________________________
FREQUENTLY ASKED QUESTIONS - PATIENTS
SUBOXONE® (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Why do I feel sick to start the medication for it to work best?
When you take your first does of SUBOXONE, if you already have high levels of another opioid in your system, the SUBOXONE will compete with
those opioids molecules and replace them at the receptor sites. By already being in mild to moderate withdrawal when you take your first dose of
SUBOXONE, the medication will make you feel noticeably better, not worse.
How does SUBOXONE work?
SUBOXONE binds to the same receptors as other opioid drugs. It mimics the effects of other opioids by alleviating cravings and withdrawal symptoms. This allows you to address the psychological reasons behind your opioid use.
When will I start to feel better?
Most patients feel a measurable improvement in 30 minutes, with full effects clearly noticeable after 1 hour.
How long will SUBOXONE last?
After the first hour, many people say they feel pretty good for most of the day. Response to SUBOXONE will vary based on factors such as tolerance and metabolism, so each patient’s dosing is individualized. Your doctor may increase your dose of SUBOXONE during the first week to help
keep you from feeling sick.
Can I go to work right after my first dose?
SUBOXONE can cause drowsiness and slow reaction times. These responses are more likely over the first few weeks of treatment, when your
dose is being adjusted. During this time, your ability to drive, operate machinery, and play sports may be affected. Some people do go to work right
after their first SUBOXONE dose; however, many people prefer to take the first and possible the second day off until they feel better.
Is it important to take my medication at the same time each day?
In order to make sure that you do not get sick’ it is important to take your medication at the same time every day.
If I have more than one tablet, do I need to take them together at the same time?
Yes and no – you need to take your dose at one “sitting”, but you do not necessarily need to fit all the tablets under your tongue simultaneously.
Some people prefer to take their tablets this way because it’s faster, but this way may not be what works best for you. The most important thing is to
be sure to take the full daily dose you were prescribed, so that your body maintains constant levels of SUBOXONE.
Why does SUBOXONE need to be placed under the tongue?
There are two large veins under your tongue (you can see them with a mirror). Placing the medication under your tongue allows SUBOXONE to
absorb quickly and safely through these veins as the tablet dissolves. If you chew or swallow your medication, it will not be correctly absorbed as it
is extensively metabolized by the liver. Similarly, if the medication is not allow to dissolve completely, you won’t receive the full effect.
Why can’t I talk while the medication is dissolving under my tongue?
When you tlak, your move your tongue, which lets the undissolved SUBOXONE “leak” out from underneath, thereby, preventing it from being absorbed by
the two veins. Entertaining yourself by readying or watching television while your medication dissolves can help the time to pass more quickly.
Why does it sometimes only take 5 minutes for SUBOXONE to dissolve and other times it takes much longer?
Generally, it takes about 5-10 minutes for a tablet to dissolve. However, other factors (e.g., the moisture of your mouth) can effect that time. Drinking something before taking your medication is a good way to help the tablet dissolve more quickly.
If I forget to take my SUBOXONE for a day will I feel sick?
SUBOXONE works best when taken every 24 hours, however, it may last longer than 24 hours, so you may not get sick. If you miss your dose, try
to take it as soon as possible, unless it is almost time for your next dose. If it is almost time for your next dose, just skip the dose you forgot, and
take next dose as prescribed. Do not take two doses at once unless directed to do so by your physician. In the future, the best way to help yourself
remember to take your medication is to starting taking it at the same time that you perform a routine, daily activity, such as when you get dressed in
the morning. This way, the daily activity will state to serve as a reminder to take your SUBOXONE.
What happens if I still feel sick after taking SUBOXONE for a while?
There are some reasons why you may still feel sick. You may not be taking the medication correctly or the dose may not be right for you. It is important to tell your doctor or nurse if you still feel sick.
What happens if I take drugs and then take SUBOXONE?
You will probably feel very sick and experience what is called “precipitated withdrawal” SUBOXONE competes with other opioids and will displace those
opioid molecules from the receptors. Because SUBOXONE has less opioid effects that full against opioids, you will go into withdrawal and feel sick.
What are the side effects of this medication?
Some of the most common side effects that patients experience are nausea, headache, constipation, and body aches and pains. However, most
side effects see with SUBOXONE appear during the first week or two of treatment, and then generally subside. If you are experiencing any side
effects, be sure to talk about it with your doctor or nurse, as he/she can often teat those symptoms effectively until they abate on their own.
Confidentiality of Alcohol and Drug Dependence Patient Records
The confidentiality of alcohol and drug dependence patients’ records maintained by this practice/program is protected by federal law and regulations.Generally, the practice/program may not say to a person outside the practice/program that a patient attends the practice/program, or disclose
any information identifying a patient as being alcohol or drug dependent unless:
1. The patient consents in writing.
2. The disclosure is allowed by a court order, or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or practice/program evaluation.
Violation of the federal law and regulations by a practice/program is a crime. Suspected violations reported to appropriate authorities in accordance
with federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime.
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.
q Scott Balogh, MD, FASAM, ABAM, ABPN
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
q Other: ____________________________________
EXPLANATION OF TREATMENT
SUBOXONE® (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet
Intake
You will be given a comprehensive substance dependence assessment, as well as an evaluation of
mental status and physical exam. The pros and cons of the medication, SUBOXONE, will be presented.
Treatment expectations, as well as issues involved with maintenance versus medically supervised
withdrawal will be discussed.
Introduction
You will be switched from your current opioid (heroin, methadone, or prescription painkillers) on to
SUBOXONE. At the time of induction, you will be asked to provide a urine sample to confirm the presence
of opioids and possibly other drugs. You must arrive for the first visit experiencing mild to moderate opioid
withdrawal systems. Arrangements will be made for you to receive your first dose in the doctors’ office.
Your response to the initial dose will be monitored. You may receive additional medication, if necessary,
to reduce withdrawal symptoms.
Since an individual’s tolerance and reactions to SUBLOXONE vary, daily appointments may be scheduled
and medications will be adjusted until you no longer experience withdrawal symptoms or cravings. Urine drug
screening is typically required for all patients at every visit during this phase.
Intake and Induction may both occur at the first visit, depending on your needs and your doctor’s evaluation.
Stabilization
Once the appropriate dose of SUBOXONE is established, you will stay at this dose until steady blood levels
are achieved. You and your doctor will discuss your treatment options from this point forward.
Maintenance
Treatment compliance and progress will be monitored. Participation in some form of behavioral counseling
is strongly recommenced to ensure best chance of treatment success. You are like to have scheduled
appointments on a weekly basis, however, if treatment progress is good and goals are met, monthly visits
will eventually be considered sufficient. The Maintenance Phase can last from weeks to years – the length
of treatment will be determined by you and your doctor, and, possibly, you counselor. Your length of
treatment may vary depending on your individual needs.
Medically Supervised Withdrawal
As your treatment progresses, you and your doctor may eventually decide that medically supervised
withdrawal is an appropriate option for you. In this phase, your doctor will gradually taper your SUBOXONE
dose over time, taking care to see that you do no experience any withdrawal symptoms or cravings.
q Scott Balogh, MD, FASAM, ABAM, ABPN
q Daniel Sumrok, MD, FASAM, ABAM, FAAFP
1325 Eastmoreland Ave, Suite 440
Memphis, Tennessee 38104
P 901.866.8630 •  F 901.302.2630
q Other: ____________________________________
UNDERSTANDING OPIOID DEPENDENCE
SUBOXONE® (buprenorphine HCI/naloxone HCI dehydrate) sublingual tablet
Opioid dependence is a disease in which there are biological or physical, and social changes. Some of the physical
changes include the need for increasing amounts of opioid to produce the same effect, symptoms of withdrawal, feelings
of craving and changes in sleep patterns. Psychological components of opioid dependence include a reliance on heroin or
other drugs to help you cope with everyday problems or inability to feel good or celebrate without using heroin or opioids.
The social components of opioid dependence include less frequent contact with important people in your life, and inability
to participate in important events due to drug use. In extreme cases, there may even to criminal and legal implications.
The hallmarks of opioid dependence are the continued use of drugs despite their negative affect, the need for increasing
amounts of opioids to have the same effect and the development of withdrawal systems upon cessation.
There are a variety of factors that can contribute to the continued use of opioids. Among these are the use of heroin to
escape from or cope with problems, the need to use increasing amounts for heroin to achieve the same effect, and the
need for a “high”.
Treatment
Treatments for opioid dependence is best considered a long-term process.
Recovery from opioid dependence is not an easy or painless process, as it involves changes in drug use and lifestyle,
such as adopting new coping skills. Recovery can involve hard work, commitment, discipline, and a willingness to examine the effects of opioid dependence on your life. At first, it isn’t unusual to feel impatient, angry, or frustrated.
The changes you need to make will depend on how opioid dependence has specifically affected your life. The following
are some of the common areas of change to thing about when developing your specific recovery plan.
Physical-good nutrition, exercise, sleep and relaxation.
Emoitional – learning to cope with feelings, problems, stresses and negative thinking without relying on opioids.
Social – developing relationships with sober people, learning to resist pressures from others to use or misue substances,
and developing healthy social and leisure interests to occupy your time and giver you a sense of satisfaction and pleasure.
Family – examining the impact opioid dependence has had on your family, encouraging the to get invoiced in treatment,
mending relationships with family members, and working hard to have mutallay satisfying relationships with family members,
Spiritual – learning to list to your inner voice for support and strength, and using that voice to guide you in developing a
renewed sense of purpose and meaning.
It is common for people to think of substance dependence as a weakness in character, instead of a disease. Perhaps the first
few times the person used drugs it was poor judgement. However, by the time the patient became dependent, taking drugs
every day, and needing medical treatment, it can be considered a “brain disease” rather than a problem with willpower.
In summary:
Family support can be very helpful to patients on SUBOXONE treatment. It helps if the family members understand
how dependence is a chronic disease that requires ongoing care. It also helps fi the family gets to know a little about
how treatment with SUBOXONE WORKS, and how it should be stored at home to keep it safe. Family lie might have
to change to allow time and effort for the patient to become healthy again. Sometimes family members themselves can
benefit from therapy.