Opioid Use Disorder Screening Template
Patient Name
Date
Opioid Use History
Current opioid use?
Yes
No
Duration of opioid use (months/years)
Type(s) of opioids used
Screening Questions
Craving opioids
Loss of control over opioid use
Use despite social/interpersonal problems
Significant time spent obtaining, using, or recovering
Use in physically hazardous situations
Experience of withdrawal symptoms
Tolerance: need for increased amount to achieve effect
Comments
Additional notes