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Suboxone Patient Form

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Patient Information















Male Female










Medical History


Asthma/respiratory
Hypertension
Cardiovascular(heart attack,cholesterol)
Epilepsy or seizure disorder
            HIV/AIDS
Diabetes
Thyroid Disease
Other


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Social/Family History


Married   Single   Long-term relationship   Divorced/Separated


Yes No


Graduate school   College   Professional or Vocational school  
High school   Grade



Yes   No


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Yes No

Substance Abuse History



Yes No


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Yes No