Client Information

OTHER COMPANY ACTIONS:

A) OPIUM DERIVATIVES: HEROIN, MORPHINE, DEMEROL, METHADONE, CODEINE, PERCODAN, DILAUDID, OXYCODONE

B) BARBITURATES: AMYTAL, PHENOBARBITAL, SECONAL, NEMBUTAL, PENTOBARBITAL

C) MARIJUANA: HASHISH, CANNABIS

D) AMPHETAMINES: BENZEDRINE, DEXEDRINE, METHEDRINE, PRELUDIN

E) COCAINE

F) HALLUCINOGENS: LSD, DMT, MESCALINE, PEYOTE, PSILOCYBIN, PCP

G) SEDATIVES AND TRANQUILIZERS: LIBRIUM, VALIUM, QUAALUDE, DELMANE, PLACIDYL

1B) WERE ANY OF THESE PRESCRIBED BY A PHYSICIAN?

TYPE

USUAL QUANTITY

FREQUENCY OF USE

DATE (FROM)

DATE (TO)