OMB Control No. 0910-0847
Attachment B
Prescription Opioids
Please check all the brand names you recall using during the past 12 months. If you do not recall the brand name, just check the generic name.
Generic Names |
Brand Names |
Please check if you have used during 12 months prior to beginning treatment |
Hydrocodone |
|
|
|
Anexia |
|
Hysingla ER |
|
|
Lortab |
|
|
Lorcet |
|
|
Norco |
|
|
Reprexain |
|
|
Vicodin |
|
|
Vicoprofen |
|
|
Zohydro ER |
|
|
Oxycodone |
|
|
|
Oxaydo |
|
Oxycet |
|
|
Oxycontin |
|
|
Percocet |
|
|
Percodan |
|
|
Roxicet |
|
|
Roxicodone |
|
|
Xartemis XR |
|
|
Xtampza ER |
|
|
Morphine |
|
|
|
Astramorph PF (injectable) |
|
Duramorph (injectable) |
|
|
Embeda |
|
|
Infumorph (injectable) |
|
|
Kadian |
|
|
Morphobond |
|
|
MS Contin |
|
|
Pharmaceutical Fentanyl |
|
|
|
Abstral |
|
|
Actiq |
|
|
Duragesic |
|
|
Fentora |
|
|
Ionsys |
|
|
Lazanda |
|
|
Onsolis |
|
|
Sublimaze |
|
|
Subsys |
|
Generic Names |
Brand Names |
Please check if you have used during 12 months prior to beginning treatment |
Codeine |
|
|
|
Floricet with codeine |
|
Florinal with codeine |
|
|
Tylenol #3 |
|
|
Tylenol #4 |
|
|
Methadone |
|
|
|
Dolophine |
|
Methadose |
|
|
Tramadol |
|
|
|
Conzip |
|
Ultracet |
|
|
Ultram |
|
|
Ultram ER |
|
|
Oxymorphone |
|
|
|
Opana |
|
Opana ER |
|
|
Hydromorphone |
|
|
|
Dilaudid |
|
|
Dalaudid-HP |
|
|
Exalgo |
|
Buprenorphine |
|
|
|
Belbuca |
|
|
Bunavail |
|
|
Buprenex |
|
|
Butrans |
|
|
Suboxone |
|
|
Zubsolv |
|
Tapentadol |
|
|
|
Nucynta |
|
|
Nucynta ER |
|
Meperidine |
|
|
|
Demerol |
|
Butorphanol |
(no brand name) |
|
Pentazocine |
|
|
|
Talwin |
|
Alfentanil |
|
|
|
Alfenta |
|
Remifentanil |
|
|
|
Ultiva |
|
Sufentanil |
|
|
|
Dsuvia |
|
|
Sufenta |
|
Dihydrocodeine |
|
|
|
Synalgos-DC |
|
First Name: ________ Date/Time of Full Interview with MHA: _______________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Mark Herring |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |