Interactive Opioid Risk Tool

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Download Printable Copy of Blank ORT Form

Patient Gender: Reset Male Female

Question	Assessment	Score
ORT Addiction and Diversion Risk
ORT-1A:Family History of Substance Abuse (Alcohol)	Yes No
ORT-1B:Family History of Substance Abuse (Illegal Drugs)	Yes No
ORT-1C:Family History of Substance Abuse (Prescription Drugs)	Yes No
ORT-2A:Personal History of Substance Abuse (Alcohol)	Yes No
ORT-2B:Personal History of Substance Abuse (Illegal Drugs)	Yes No
ORT-2C:Personal History of Substance Abuse (Prescription Drugs)	Yes No
ORT-3:Age (Age 1-45)	Yes No
ORT-4:History of Preadolescent Sexual Abuse	Yes No
ORT-5A:Psychological Disease (Attention Deficit Disorder, Obsessive Compulsive Disorder, Bipolar, Schizophrenia)	Yes No
ORT-5B:Psychological Disease (Depression)	Yes No
ORT-SUM: Sum of Above

Urine Drug Testing Recommendation.

Recommendation Text Goes here.

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