Talking with a provider

Directions: You can fill out this form to take with you to help you talk to your provider about what is important to you.

Talking with your provider about an opioid use disorder can be challenging. Use this Recovery Tool to help you talk with your provider. After completing the form, take a copy with you to help you talk to your provider about what is important to you.

The interactive tools on this site do not store information. You can enter your information and print out the worksheets and questionnaires for your own use. No personal information is recorded or stored. This protects the confidential nature of the information.

To save your information for your future use, print out the completed form before you leave the page. You can also save the completed form as a file on your personal computer or email it to yourself or someone you trust.

1. Prepare

What questions do you have? What information do you need? (Check all that apply.)

Can you tell me what other kinds of help are available? Choose from this list or enter others you need.

List any other concerns:

2. Gather Your Information

The provider will want to know this information about you. Enter your information below each statement.

List all of your current health conditions and concerns:

List all medications you are taking prescribed to you by a doctor and any supplements you take: Dates and details of any past or current treatment for opioid use disorder (For example: where, when and how it worked out):

List the opioid drugs you have been using, how long, and an estimate of how much:

List any other legal and illicit drugs you use (For example: marijuana, tobacco, valium, alcohol, etc.):

Remember: Bring any paperwork, relevant medical records, and test results that you have to your appointment.

Talking with a provider

Below are your answers to the questionnaire that you just finished. Located at the top of this page, you will find icons either to print or email the results to your provider.