Synthetic Cannabinoid Use - Patient (or Surrogate) Inter

Form Approved;

OMB No. 0920-1011;

Exp Date: 03/31/2017

Adverse Health Effects Associated with
Synthetic Cannabinoid Use — Mississippi, 2015

PATIENT (OR SURROGATE) INTERVIEW

Reviewer/Interviewer:____________________________Agency:___________________Date:(mm/dd/yy):____________

Emergency Department (ED):_________________________or Coroner/Medical Examiner Name___________________

pATIENT identification (prepopulate from medical record if applicable)
Full Name (Last Name, First Name)			Medical Record Number
Date of Birth (mm/dd/yy)	Age			Sex
Address
City/State/Zip
Phone/Home		Phone/Cell

demographics I will start by asking some demographic questions
Ethnicity: Hispanic or Latino ☐ Yes ☐ No ☐ Don’t Know ☐ Refused	Race (check all that apply): ☐Amer Ind/AK native ☐Asian ☐ Black/Afr Am ☐Native HI/other PI ☐White ☐Other (specify)___________________________ ☐ Don’t Know ☐Refused
Are you a student? ☐ Yes ☐ No ☐ Refused If yes: which level? ☐ Elementary ☐ Junior high ☐High school ☐ College ☐ Vocational/trade school ☐ Graduate School Are you employed? ☐Yes ☐ No ☐ Refused
PAST MEDICAL HISTORY Now I want to shift and ask you about your general health and health history.
Prior to your recent visit to the ER, would you say your health was ☐ Very good ☐ Good ☐ Fair ☐ Poor ☐Very poor ☐ Don’t know ☐ Refused Prior to you recent visit to the ER, had a doctor or nurse ever told you that you have… High blood pressure: ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Heart disease: ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Specify___________________________ Kidney disease: ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Specify___________________________ Liver disease: ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Specify___________________________ Diabetes ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Seizure disorder ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Specify___________________________ Mental illness ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Specify___________________________ Substance addiction ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Specify___________________________ Other ☐ Yes ☐ No ☐ Don’t Know ☐ Refused Specify___________________________ Do you regularly take any medicine prescribed by your doctor? ☐ Yes ☐ No ☐ Don’t Know ☐ Refused If yes: please tell me three things: the name of each medication you take; the reason why, or the health condition for which you take it; and finally, whether you took any of these medicines in the 24 hours before your visit to the ER. Name: ___________________ Condition: ___________________ ☐ used in 24 hours before visit to ER Name: ___________________ Condition: ___________________ ☐ used in 24 hours before visit to ER Name: ___________________ Condition: ___________________ ☐ used in 24 hours before visit to ER Name: ___________________ Condition: ___________________ ☐ used in 24 hours before visit to ER
RECREATIONAL DRUG EXPOSURES AT TIME OF ILLNESS ONSET Now I’m going to ask you about the substance(s) you used 24 hours before going to the ER. This information will not be shared with any law enforcement and may help us prevent others from getting sick.
Did you drink any alcoholic beverages during the 24 hours before your recent visit to the ER? ☐ Yes ☐ No ☐ Don’t know ☐ Refused If yes: was this your first time using alcohol? ☐Yes ☐ No ☐ Don’t know ☐ Refused If yes: please specify type of alcoholic beverage and amount consumed (be as specific as possible, for example 3 8-oz. beers or 2 shots of tequila)__________________________________________ Did you use synthetic or “fake” marijuana during the 24 hours before your recent visit to the ER? ☐ Yes ☐ No ☐ Don’t know (skip to question 11) ☐ Refused (skip to question 11) If yes: when you were using it did you know you were using synthetic or “fake” marijuana? ☐ Yes ☐ No ☐ Don’t know ☐ Refused If no: what substance did you think you were using__________________________ Approximately how long after you used synthetic or “fake” marijuana did you first feel sick? Specify in minutes_______________________ ☐ Don’t Know ☐ Refused Did you use any prescription medicine or over-the-counter medicine for non-medical reasons during the 24 hours before your recent visit to the ER? ☐ Yes ☐ No ☐ Don’t know ☐ Refused If yes: please specify___________________________________________ Did you use any other recreational substances(s) during the 24 hours before your recent visit to the ER? This would include recreational substances such as cocaine, meth, heroin, and others. ☐ Yes ☐ No ☐ Don’t know ☐ Refused If yes: specify drug(s)______________________________________________________________ In what order or combination did you take these substances during the 24 hours before you first felt sick? If no drug history (i.e. Questions 9, 11, 12 are all No, Don’t know, or Refused) GO TO CLOSING STATEMENT.
DETAILS OF RECENT RECREATIONAL DRUG USE Now I am going to ask you about each recreational drug or medication you used during the 24 hours before your ER visit
Note: Chart synthetic marijuana first and DO NOT chart alcohol.
Substance # 1: ________________________ 14.1 Thinking about the (substance 1) you used during the 24 hours before your recent visit to the ER, did this (substance 1) have a brand/street name___________________________ ☐ Don’t Know ☐ Refused Please describe the packaging: ________________________________ ☐ Don’t Know ☐ Refused 14.2 Was this your first time using this substance? ☐Yes ☐ No ☐ Don’t Know ☐ Refused If yes, skip to question 14.7 14.3 Have you used this specific brand before ☐Yes ☐No ☐Don’t Know ☐Refused If no, skip to question 14.7 If yes: how many times? ☐ Once ☐ 2-5 times ☐ > 5 times 14.4 Have you been sick before after using this brand? ☐Yes ☐No ☐Don’t Know ☐Refused 14.5 Did using this substance make you feel the same way it did other times you have used it? ☐Yes ☐ No ☐Don’t Know ☐Refused Notes (optional)_______________________________ 14.6 Did the substance taste or smell like it did the other times you have used it? ☐Yes ☐ No ☐ Don’t Know ☐ Refused Notes (optional)_______________________________ 14.7 How did you use this substance during the 24 hours before your recent visit to the ER? ☐Smoke ☐Eat or Swallow ☐ Snort ☐ Intravenous ☐ Other____________ 14.8 Did you use it in a different way than you usually use it? ☐Yes ☐No ☐ Don’t have normal method ☐ Don’t Know ☐ Refused 14.9 How much of this substance did you use during the 24 hours before your recent visit to the ER? amount = _______ unit (check only one) =☐ grams ☐ packets ☐ puffs ☐ hits ☐ bowls ☐ blunts ☐other, specify_____________________ ☐ Don’t Know 14.10 How did you get this substance? please, check all that apply ☐ convenience store ☐ gas station ☐ tobacco store ☐ head shop ☐ pharmacy Please specify store name/location: ____________________________________ ☐ dealer ☐ friend ☐ family member ☐ internet, please specify website ________________________________ ☐ event (e.g. party), please specify________________________________ ☐ other, please specify_________________________________________ ☐ Don’t know ☐ Refused 14.11 How many days before your recent visit to the ER did you get this substance? ☐ Same Day (0 days) ☐ # of Days _________ ☐ Don’t know ☐ Refused 14.12 If you got it from a friend, family member, an acquaintance, or a dealer, where did they get it from? check all that apply ☐ convenience store ☐ gas station ☐ tobacco store ☐ head shop ☐ pharmacy Please specify store name/location: ____________________________________ ☐ dealer ☐ friend ☐ family member ☐ internet, please specify website ________________________________ ☐ event (e.g. party), please specify________________________________ ☐ other, please specify_________________________________________ ☐ Don’t know ☐ Refused 14.13 Did anyone else you know use this substance from the same source (same packet, baggy, joint, etc.)? ☐ Yes ☐ No ☐ Don’t Know ☐ Refused If yes: do you know if these people also got sick? ☐ Yes ☐ No ☐ Don’t Know ☐ Refused If yes: did they have to go to the hospital because of it? ☐ Yes ☐ No ☐ Don’t Know ☐Refused Repeat “DETAILS OF RECENT RECREATIONAL DRUG USE” section (use Appendix A) for each recreational drug. If no history of synthetic marijuana use, skip to AWARENESS QUESTIONS.
SYNTHETIC MARIJUANA USE (GENERAL) Now I am going to ask you general questions about your use of synthetic marijuana
How often do you use synthetic or “fake” marijuana? ☐ one time only (this episode) ☐ less than once a month ☐ 1-3 times a month ☐ once a week ☐ 2-3 times a week ☐ 4 - 6 times a week ☐ once a day ☐ more than once a day ☐ Refused If one time only, skip to question 17 How long have you been using synthetic or “fake” marijuana at this frequency? ☐ first time ☐ less than 1 year ☐ 1–2 years ☐ 3–5 years ☐ 6–10 years ☐ more than 10 years ☐ Don’t Know ☐Refused How old were you when you first tried synthetic or “fake” marijuana? Age (in years)______ ☐ Don’t Know ☐ Refused Why do you choose to use synthetic or “fake” marijuana? ___________________________________
AWARENESS QUESTIONS Finally, I want to ask you about your awareness of synthetic marijuana and a few closing questions
Before your recent visit to the ER, were you aware that using synthetic or “fake” marijuana could cause severe illness? ☐ Yes ☐ No ☐ Don’t Know ☐Refused Are you aware that over the last month many people in the state of Colorado have been getting sick after using synthetic or “fake” marijuana? ☐ Yes ☐ No ☐ Don’t know ☐ Refused If yes: how did you find out? (check all that apply) ☐TV/Radio, specify_______________________ ☐Social media (e.g. Facebook, Twitter, Instagram), specify___________________ ☐ internet website (specify)_______________________ ☐ friend ☐family member ☐other (specify)________________________________ Have you continued to use synthetic or “fake” marijuana since your recent visit to the ER? ☐ Yes ☐ No ☐ Don’t Know ☐Refused
CLOSING QUESTIONS/COMMENT
What contact information works best if another public health person needs to speak with you again? ___________________________________________________ ☐ Don’t Know ☐ Refused If you have any leftover product(s) from the 24 hours before your illness started, would you be willing to provide it for possible testing? ☐ Yes ☐ No Notes/Comments/Questions:
APPENDIX A MRN:_______________________ Last Name: _________________________
Substance #_____: ___________________ 14.1 Thinking about the (substance 1) you used during the 24 hours before your recent visit to the ER, did this (substance 1) have a brand/street name___________________________ ☐ Don’t Know ☐ Refused Please describe the packaging: ________________________________ ☐ Don’t Know ☐ Refused 14.2 Was this your first time using this substance? ☐Yes ☐ No ☐ Don’t Know ☐ Refused If yes, skip to question 14.7 14.3 Have you used this specific brand before ☐Yes ☐No ☐Don’t Know ☐Refused If no, skip to question 14.7 If yes: how many times? ☐ Once ☐ 2-5 times ☐ > 5 times 14.4 Have you been sick before after using this brand? ☐Yes ☐No ☐Don’t Know ☐Refused 14.5 Did using this substance make you feel the same way it did other times you have used it? ☐Yes ☐ No ☐Don’t Know ☐Refused Notes (optional)_______________________________ 14.6 Did the substance taste or smell like it did the other times you have used it? ☐Yes ☐ No ☐ Don’t Know ☐ Refused Notes (optional)_______________________________ 14.7 How did you use this substance during the 24 hours before your recent visit to the ER? ☐Smoke ☐Eat or Swallow ☐ Snort ☐ Intravenous ☐ Other____________ 14.8 Did you use it in a different way than you usually use it? ☐Yes ☐No ☐ Don’t have normal method ☐ Don’t Know ☐ Refused 14.9 How much of this substance did you use during the 24 hours before your recent visit to the ER? amount = _______ unit (check only one) =☐ grams ☐ packets ☐ puffs ☐ hits ☐ bowls ☐ blunts ☐other, specify_____________________ ☐ Don’t Know 14.10 How did you get this substance? please, check all that apply ☐ convenience store ☐ gas station ☐ tobacco store ☐ head shop ☐ pharmacy Please specify store name/location: ____________________________________ ☐ dealer ☐ friend ☐ family member ☐ internet, please specify website ________________________________ ☐ event (e.g. party), please specify________________________________ ☐ other, please specify_________________________________________ ☐ Don’t know ☐ Refused 14.11 How many days before your recent visit to the ER did you get this substance? ☐ Same Day (0 days) ☐ # of Days _________ ☐ Don’t know ☐ Refused 14.12 If you got it from a friend, family member, an acquaintance, or a dealer, where did they get it from? check all that apply ☐ convenience store ☐ gas station ☐ tobacco store ☐ head shop ☐ pharmacy Please specify store name/location: ____________________________________ ☐ dealer ☐ friend ☐ family member ☐ internet, please specify website ________________________________ ☐ event (e.g. party), please specify________________________________ ☐ other, please specify_________________________________________ ☐ Don’t know ☐ Refused 14.13 Did anyone else you know use this substance from the same source (same packet, baggy, joint, etc.)? ☐ Yes ☐ No ☐ Don’t Know ☐ Refused If yes: do you know if these people also got sick? ☐ Yes ☐ No ☐ Don’t Know ☐ Refused If yes: did they have to go to the hospital because of it? ☐ Yes ☐ No ☐ Don’t Know ☐Refused

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