Opioid Risk Tool (ORT) Assessment Instrument

Reprinted With Permission from Lynn Webster, MD

More Information on ORT

Printable Version of ORT


 

OPIOID RISK TOOL PATIENT FORM

Name:__________________________________

Age:_________

  Mark Each Box That Applies
Score if Female
Score if Male
 1.  Family History of Substance Abuse
  • Alcohol
  • Illegal Drugs
  • Prescription Drugs

1

2

4

3

3

4

 2.  Personal History of Substance Abuse
  •  Alcohol
  • Illegal Drugs
  • Prescription Drugs

3

4

5

3

4

5

3.  Age (Mark Box if 16-45 years)

  1 1

4.  History of Preadolescence Sexual Abuse

  3 0
 5.  Psychological Disease
  •  Attention-Deficit/Hyperactivity Disorder; Obsessive Compulsive Disorder; Bipolar Disorder; Schizophrenia
  • Depression

2

1

2

1

Total Score ________Risk Category_________

Low Risk 0-3

Moderate Risk 4-7

High Risk >7

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