BELLA NIRVANA CENTER DAILY DETOX

No of days of detox
Date
Client Name:
Date Of Birth:
How is your detox coming along?
Vital signs:
BP Pulse RR Temp
ROS:
N/V
Diarrhea
Constipation
Fever
SOB
Body Ache
HA
Chest pain
Anxiety
Running nose
Patient denies any nausea, vomiting, diarrhea, chest pain, shortness of breath, abdominal pain, headache, fever. chills, body ache

Cravings? Yes No   If yes,

On Scale 1 2 3 4 5 6 7 8 9 10 What can we do?

Anger/Agitation/Hallucination? Yes No

1 2 3 4 5 6 7 8 9 10
What can we do?

Anxiety? Yes No

1 2 3 4 5 6 7 8 9 10
What can we do?

Depression? Yes No

1 2 3 4 5 6 7 8 9 10
What can we do?

Any Homicidal and Suicidal thoughts ? Yes No   If yes,

Passive thought
Have a plan Do you need to talk to counselor or Provider Yes No

How is your Sleep Good Fair Poor

No of hours sleep
Other concerns: