Opioid Assessment Questionnaire | MetroWellness

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Opioid Assessment Questionnaire

Could It Be Opioid Dependence?

Think you or someone you know may have opioid dependence? This simple questionnaire, based on DSM-5* criteria for opioid use disorder, can help you determine if it may be time to talk to a health care provider. Answer the questions below as accurately and honestly as you can.

Opioid Assessment

Name*
Phone*
Email*
- Do you/they use opioids in larger amounts or for a longer period of time than your/their doctor prescribed?
- Do you/they have a persistent desire or have you/they had unsuccessful efforts to cut down or control opioid use?
- Do you/they spend a great deal of time trying to obtain or use opioids?
- Do you/they have a strong desire or urge to take opioids?
- Has your/their opioid use resulted in a failure to fulfill major role obligations at work, school, or home?
- Do you/they continue to use opioids despite continuing or repeated social or personal problems caused or worsened by the effects of opioids?
- Have you/they lost interest in former recreational activities or hobbies because of opioid use?
- Have you/they given up or reduced social activities because of opioid use?
- Do you/they continue to misuse opioids even though you/they know it has harmful consequences?
- Do you/they have difficulty controlling opioid use?
- Without the direction of a doctor, do you/they take a higher dose of opioids in order to achieve the effects originally produced by lower doses?
- When you/they stop or reduce the amount of opioids, do you/they experience withdrawal symptoms (eg, cramps, diarrhea, runny nose, tearing, sweating, chills, yawning, muscle pain, nausea, or vomiting)?
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Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.
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