Skip to main content

Controlled drug (CD)/Opioid request

Important: Information

You have been sent this form to fill in because one of the medications you have requested is either an opioid or a controlled drug.

Please check your answers before submitting the form as your medical records will be updated with the information you have provided.

If you feel you have been incorrectly sent this, please phone after 2pm and ask to speak to the prescriptions team.

Controlled Drug (CD) / Opioid

Section

What is the name of your controlled drug / opioid? *
With controlled drugs / opioids it is important to consider non-medication approaches to help your symptoms. This can help to reduce your medication usage or to eventually help you stop the medication. For now do you want to: *

Please be aware of the following in terms of controlled drugs / opioids and tick once read and understood: *
If you are unable to confirm, please phone the prescriptions team to discuss further.
Do you feel you are addicted to the medication you are on? *
Do you take any illicit drugs? *
We would recommend a referral to the STARS addiction team. *

Please download a STARS Online Referral form and send this to humankind.starseast@nhs.net after you have submitted this form.

Smoking

Smoking status: *
Would you like help to quit smoking? *

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *
*