Medication-Assisted Treatment (MAT) Screening
Patient Information
Name
Date of Birth
Medical Record Number
Substance Use History
Primary Substance Used
Duration of Use
Date/Time of Last Use
Previous MAT (Type and Date)
Withdrawal Symptoms
Symptoms Present
Yes
No
Description
Medical/Psychiatric History
Medical Conditions
Psychiatric History
Current Medications
Assessment & Plan
MAT Eligibility
Eligible
Not Eligible
Needs Further Evaluation
Additional Notes