Microsoft word - res-675

Residential Substance Abuse and Detoxification Programs Telephone (808) 579-9584 Fax (808) 579-8902
Dear Physician,
Thank you for working with this patient/client as they seek admission to the Aloha House Substance Abuse Treatment.
Your role is extremely important for the patient/client to be admitted to Aloha House. We are a medical y monitored
detoxification and treatment program. We have nurses on staff and a Medical Director; however, our license does not
allow us to have admitting or prescribing physicians on staff. We rely on community physicians to fulfill this
role.

There are 6 pages attached and each one is vital to the admission. We have made them as quick and simple as possible
for you. Please complete each page; there are also brief instructions on each page.
PLEASE FAX ALL COMPLETED FORMS TO ALOHA HOUSE AT (808) 579-8902.

1. Release of Information: Patient/client must initial and sign where indicated. Please fil in your name at top
where indicated. This is vital; we cannot talk to you without this form in our hands. 2. Physical History and Screening: Simple questionnaire.
3. Physical Exam
4. Physician Orders:
a. Please check only one protocol and prescribe for the alcohol or drug detox orders.
b. If client uses both opiates and alcohol, please prescribe the priority protocol, the opiate PRN protocol
c. Additional y, please prescribe Vistaril and Trazodone for al clients as indicated. d. Prescribe any other medication the patient/client is currently taking except control ed substances. 5. Standing Orders: Self explanatory, please sign at the bottom.
Please give the prescriptions to the patient/client and/or cal a pharmacy for al prescription orders. The
patient/client must pick up and bring in ALL medications needed, in order to be admitted into Aloha House.
BEFORE RELEASING THE PATIENT/CLIENT, PLEASE FAX FORMS AND WAIT FOR THE NURSE TO CALL
AND CONFIRM THE ADMISSION. AT THAT TIME THE NURSE MAY DISCUSS QUESTIONS ABOUT THE
FORMS.
Thank you very much for your cooperation and please feel free to call if you have any questions.
PLEASE FAX ALL COMPLETED FORMS TO
ALOHA HOUSE AT (808) 579-8902.
Residential Substance Abuse and Detoxification Programs Telephone (808) 579-9584 Fax (808) 579-8902 INTERIM CARE AND STABILIZATION PROGRAM
CLIENT SCREENING (MD TO COMPLETE)
Client Name: _______________________________________________ Age: _______ DOB: __________________

Address: ______________________________________________________________________________________
City___________________ Zip ____________ Phone ______________________ SS# ________________________
Substances Used/Abused
Please be specific as possible in Use(d)?
your answers. Thank you.
Has client injected any of the above? (check one) YES or NO
If yes, what has been injected? ____________________________________________________________________
When was the last time of injection? ________________________________________________________________
For how long has client been injecting substances? ___________________________________________________
PLEASE FAX ALL COMPLETED FORMS TO
ALOHA HOUSE AT (808) 579-8902.
Residential Substance Abuse and Detoxification Programs Telephone (808) 579-9584 Fax (808) 579-8902 PHYSICAL EXAM SCREENING (PHYSICIAN COMPLETES)
Client Name: ________________________________________________ Is the client presently under the influence of alcohol and/or other drugs? (check one) YES or NO
If yes, what substances?_____________________________________________________________________ Is the client presently having withdrawal symptoms? (check one) YES or NO
If yes, please describe withdrawal symptoms: ____________________________________________________ ____________________________________________________________________________________ Does the client have a history of delirium tremors? (check one) YES or NO
Any recent illnesses or diseases? (check one) YES or NO
If yes, please describe:______________________________________________________________________ ___________________________________________________________________________________ Any injuries? (check one) YES or NO
If yes, please describe: ______________________________________________________________________ Is the client taking any prescription medication? (check one) YES or NO
If yes, please specify medications: _____________________________________________________________
___________________________________________________________________________________
**NOTE: If client is to take these medications at Aloha House, please write these orders in at the bottom of
the PHYSICIAN ORDER FORM.
Has the client been hospitalized in the last year? (check one) YES or NO
If yes, please describe:______________________________________________________________________ Does the client have a psychiatric history? (check one) YES or NO
If yes, please describe:______________________________________________________________________ Any Medications?_________________________________________________________________________ Has the client been depressed recently? (check one) YES or NO
Does the client have thoughts of harming self and/or others? (check one) YES or NO
Is the client having auditory and/or visual hallucinations? (check one) YES or NO
FEMALES ONLY: Pregnant? (Please circle one) YES or NO
If yes, how many weeks/months pregnant? _______________ Date of last menstrual period: _______________ PLEASE FAX ALL COMPLETED FORMS TO
ALOHA HOUSE AT (808) 579-8902.
Residential Substance Abuse and Detoxification Programs Telephone (808) 579-9584 Fax (808) 579-8902 PRE-PLACEMENT PHYSICAL EXAMINATION
(To be completed by Physician)
Client Name (Please print):________________________________________________________________________
VITAL SIGNS T_______ P_______ R_______ BP______/______ HEIGHT_____________ WEIGHT____________
FOOD/DRUG ALLERGIES__________________________________________________________________________
HEENT _________________________________________________________________________________________
NECK __________________________________________________________________________________________
CV _____________________________________________________________________________________________
RESPIRATORY___________________________________________________________________________________
GI _____________________________________________________________________________________________
GU ____________________________________________________________________________________________
EXREMITIES_____________________________________________________________________________________
SKIN/LYMPH____________________________________________________________________________________
NEUROLOGICAL_________________________________________________________________________________
________________________________________________________________________________________________ Hepatitis A, B, or C positive? (check al that apply) Hep A Hep B Hep C
OTHER _________________________________________________________________________________________
Special ___________________________________________________________________
LABS: Please fax the fol owing when results are obtained (also include any labs appropriate to this individual):
CHEM PANEL (including Liver function tests) ____________
URINE TOX SCREEN ____________
Does the client have:
History of withdrawal seizures? (Check one) YES or NO
History of seizure disorder? (Check one) YES or NO
If yes, what medications were prescribed, if any? ________________________________________________________ ________________________________________________________________________________________________ Is this client appropriate for Residential Treatment and/or interim care placement and stabilization (detox)?
YES _______ NO _______
MD Printed Name______________________________________________________ Date______________________
MD Signature_________________________________ Phone #____________________ FAX ___________________
PLEASE FAX ALL COMPLETED FORMS TO
ALOHA HOUSE AT (808) 579-8902.
Residential Substance Abuse and Detoxification Programs Telephone (808) 579-9584 Fax (808) 579-8902 PHYSICIAN ORDER FORM (To be completed by Physician)
Client Name (Please Print):________________________________________________________________________
Examining Physician, please provide the orders and prescriptions for the following medications, if indicated.
DETOX ORDERS:
Check ONE box below for appropriate detox orders, if necessary, and prescribe medications listed. .
ALCOHOL WITHDRAWAL: Fixed-dose LIBRIUM. For clients with history of WITHDRAWAL SEIZURE or DELIRIUM TREMENS.
Librium 25 mg. #20, two PO Q6h X 4 doses, then one PO Q6h X 8 doses, then discontinue. If CIWA Ar score > 10 on fixed-dose schedule, fol ow CIWA protocol for additional Librium doses. Trazodone 50 mg. #15, one PO QHS PRN insomnia X 7 days. May repeat Q1h PRN until effective, NTE 350 mg. per night. Vistaril 50 mg. #10, one PO Q4h PRN nausea or anxiety X 7 days. ALCOHOL WITHDRAWAL: CIWA-Based LIBRIUM.
Librium 25 mg. #10, two PO PRN for CIWA-Ar score > 10.
Trazodone 50 mg. #15, one PO QHS PRN insomnia X 7 days. May repeat Q1h PRN until effective, NTE 350 mg. per night.
Vistaril 50 mg. #10, one PO Q4h PRN nausea or anxiety X 7 days.
-OR-
OPIATE WITHDRAWAL PRIMARY:
OPIATE WITHDRAWALPRN (USE IF ANOTHER SUBSTANCE IS PRIMARY):
Clonidine 0.1 mg. #8, one PO on arrival and QID X 48 hours, hold if BP < 90/60. (Hold al clonidine if using Librium) Clonidine Patch TTS-2 X 7 days, remove if BP < 90/60 or. TTS-1 Patch if client weighs less than 110 lbs. . Parafon Forte 500 mg. #10, one PO Q6h PRN muscle cramps X 7 days. Trazodone 50 mg. #15, one PO QHS PRN insomnia X 7 days. May repeat Q1h PRN until effective, NTE 350 mg. per night. Vistaril 50 mg. #10, one PO Q4h PRN nausea or anxiety X 7 days. BENZODIAZEPINE DETOXIFICATION
Administer Librium 25 mgs. P.O. Q 1 hr.PRN for withdrawal sx if 3 of 7 are present* *NOTIFY DOCTOR IF NEEDED MORE THAN FOUR (4) HRS IN A ROW
Administer Gabapentin (Neurontin):
Neurontin 300 mg BID X 1 day then,
Neurontin 300 mg TID X 10 day then DC
Neurontin 300 mg p.o. q. 1 hr. p.r.n. for anxiety. NTE 900 mg in 24 hrs. Cal MD if more needed.
Trazodone 50 mg. #15, one PO QHS PRN insomnia X 7 days. May repeat Q1h PRN until effective, NTE 350 mg. per night.
**Contact MD on 5th day after 1st dose of Neurontin for further assessment.
-OR-
METHAMPHETAMINE DETOXIFICATION
Trazodone 50 mg. #15, one PO QHS PRN insomnia X 7 days. May repeat Q1h PRN until effective, NTE 350 mg. per night. Vistaril 50 mg. #10, one PO Q4h PRN nausea or anxiety X 7 days.
PLEASE PRESCRIBE ANY OTHER MEDICATIONS THE CLIENT IS CURRENTLY TAKING, BY LISTING THEM IN THE AREA BELOW:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
MD Printed Name______________________________________________________ Date______________________
MD Signature_________________________________________________________ Phone #___________________
PLEASE FAX ALL COMPLETED FORMS TO
ALOHA HOUSE AT (808) 579-8902.
Residential Substance Abuse and Detoxification Programs Telephone (808) 579-9584 Fax (808) 579-8902 ALOHA HOUSE, INC.
Standing Orders

Client Name: ___________________________________________________
1. Multivitamin w/o iron 1 PO QD length of stay.
2. Folate 1 mg PO QD x 3 days.
3. Thiamine 100 mg PO QD x 7 days.
4. Vitamin C 500 mg 1 tab PO QD length of stay.
5. Loperamide 2 mg 2 tabs (4 mg) PO STAT for diarrhea, then 2 mg (1 tab) after each loose stool (not to exceed
6. Aspirin 325 – 650 mg PO Q4 hours PRN minor aches, headaches, fever.
7. Maalox/Mylanta 15-30 ml. or 1-2 tabs p.o. q. 4-6 hrs. PRN. for GI discomfort
8. Acetaminophen 500 mg 1 – 2 PO Q 6 hours PRN general discomfort.
9. Ibuprofen 400 – 600 mg PO Q 4 – 6 hours with food PRN general discomfort.
10. Milk of Magnesia 30-60 ml. p.o. q. hs. With large glass of water PRN. for constipation
11. Promethazine 25 mg p.r. Q 4-6 hrs. p.r.n. nausea/vomiting
12. Naproxen 220mgs 1-2 tabs q.d. PRN x 3 days for severe pain NTE 440mg in 24 hrs.
13. Chlorpheniramine 4 m. p.o. BID PRN for up to 7 days for nasal congestion r/t colds/al ergies
14. Diphenhydramine 25 mg. p.o. p.r.n. for acute al ergic reaction. May repeat once for severe reaction.

ALLERGIES: ____________________________________________________________________________________
MD Printed Name_____________________________ Phone#___________________ FAX# _________________

MD Signature_____________________________________________ Date______________________

Nurse Signature___________________________________________ Date______________________
PLEASE FAX ALL COMPLETED FORMS TO
ALOHA HOUSE AT (808) 579-8902.

Source: http://www.aloha-house.org/pdfs/Res-Intake-Form.pdf