Total Score from Questions 1-9: ______ Risk Assessment for Possible Misuse / Abuse of Chronic Opioids Opioid Risk Tool (Webster LR, Webster RM. Pain Med. 2005) Score Mark Each if if Box That Applies 1 3 1. Family History Alcohol of Substance Illegal Drugs 2 3 Abuse Prescription Drugs 4 4 3 3 Alcohol 2. Personal Illegal Drugs History of 4 4 Substance Prescription Drugs 5 5 3. Age (Mark Box 1 1 if 16-45 years) 4. History of Preadolescent 3 0 Sexual Abuse Attention-Deficit/Hyperactivity 2 2 Disorder; Obsessive Compulsive 5. Psychological Disorder; Bipolar Disorder; Disease Schizophrenia 1 1 Depression Total Score ________Risk Category_________ Low Risk 0-3 Moderate Risk 4-7 High Risk >7 Physical Exam: Vital Signs: Temp:_____ BP: ____/____ P: ______ R: _______ General: HEENT: Neck: Cardiovascular:
Total Score from Questions 1-9: ______ Risk Assessment for Possible Misuse / Abuse of Chronic Opioids Opioid Risk Tool (Webster LR, Webster RM. Pain Med. 2005) Mark Each Box That Applies Score if if 1. Family History of Substance Abuse Alcohol Illegal Drugs Prescription Drugs 1 2 4 3 3 4 2. Personal History of Substance Alcohol Illegal Drugs Prescription Drugs 3 4 5 3 4 5 3. Age (Mark Box if 16-45 years) 1 1 4. History of Preadolescent Sexual Abuse 3 0 5. Psychological Disease Attention-Deficit/Hyperactivity Disorder; Obsessive Compulsive Disorder; Bipolar Disorder; Schizophrenia Depression 2 1 2 1 Total Score ________Risk Category_________ Low Risk 0-3 Moderate Risk 4-7 High Risk >7 Physical Exam: Vital Signs: Temp:_____ BP: ____/____ P: ______ R: _______ General: HEENT: Neck: Cardiovascular:
opioid-evaluation-initial.docx