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Get Mclean At Naukeag Ambulatory Treatment Program Self-refferral Packet 2013

Nyl GHB Hallucinogens (mushrooms, LSD, PCP, DXM) Heroin Inhalants Marijuana MDMA (Ecstasy) Over the counter (cough syrup, Asthma Inhalers, Laxatives, Diet Pills, Cold Medicines, Ephedrine, Sleeping Pills, Benadryl , , Steroids (Anabolic) Tobacco Other:_____________________ MEDICATIONS: List all current medications MEDICAL Date of Last Physical:___________________________________ Primary Care Physician:___.

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