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Get McLean at Naukeag Ambulatory Treatment Program Self-Refferral Packet 2016-2024

Ines Benzodiazepines (, , ) Cocaine 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 Physi.

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