• Timeline Followback Method Illicit Substance Other Substance of Abuse Assessment Specify
• Substance Abuse Prescription Illicit Substance Over the Counter Product Domestic Partnership Spouse Complain Personal Medical History Yes No Indicator
• PROMIS Pediatric Short Form 8a Pain Interference v1.0 9004 Past 7 Days Hard to Pay Attention When in Pain Score 5 Point Scale
• PROMIS Short Form 3a Pain Intensity v1.0 PAINQU6 Past 7 Days Intensity of Pain at its Worst Score 5 Point Scale
• PROMIS Parent Proxy Short Form 8 Pain Interference v1.0 Pf3pain2 Past 7 Days Child Had Trouble Paying Attention When in Pain Score 5 Point Scale
• Substance Abuse Illicit Substance Intravenous Route of Administration Personal Medical History Yes No Indicator
• Fagerstrom Test Waking First Cigarette Score
• Timeline Followback Method Illicit Substance Amphetamine Stimulant Assessment Yes No Indicator
• Timeline Followback Method Illicit Substance Opioid Methadone Assessment Yes No Indicator
• Person Primary Care Evaluation of Mental Disorders Patient Health Questionnaire Total Score Psychometric Questionnaire Two Digit Score
• Timeline Followback Method Assessment Date
• Patient Race Specify
• Patient Health Questionnaire (PHQ-9) Problems Make It Difficult to Do Work Take Care of Things at Home or Get Along with Other People 4 Point Scale
• Patient Day Alcohol Consumption Day Alcohol Consumption Frequency Amount
• PROMIS Short Form 3a Pain Intensity v1.0 PAINQU21 Level of Current Pain Score 5 Point Scale
• Physical Well-being Not Good Past 30 Day Count
• Patient Age Year Count
• PROMIS Parent Proxy Short Form 8 Pain Interference v1.0 Pf1pain4 Past 7 Days Child Had Trouble Walking One Block When in Pain Score 5 Point Scale
• Fagerstrom Test Hardest Stop Cigarette Score
• PROMIS Pediatric Short Form 8a Pain Interference v1.0 2045R1 Past 7 Days Hard to Run When in Pain Score 5 Point Scale