Anti heroin implant Questionnaire

Doctors at our clinic treat all kinds of dependencies, but are specialized in anti heroin implant. For better understanding of your medical case, and to be able to determine if you are suitable for an implant, please fill out the following questionnaire.

1. Name and surname:

2. E-mail

3. Phone number:

4. Date of birth:

5. Height: cm

6. Weight:

7. Do you currently use substances (if yes,what substance and what is the dayle dose)?

Yes

8. Do you suffer from withdrawal symptoms?

Yes

9. Have you ever had implant in the past (do you have experience with heroin blockers)?

Yes

10. How long have you been using drugs (from the moment of the first use)?

11. Have you ever been overdosed?

Yes

12. Please indicate if you have any health problems:

Heart	Lungs
Liver	Digestive system
Other

13. Are you allergic to anything?

Yes

14. Country, City:

15. Aditional questions or comments: