This tool should be administered to patients upon an initial visit prior to beginning or
continuing opioid therapy for pain management. A score of 2 or lower indicates low risk
for future opioid use disorder; a score of >= 3 indicates high risk for opioid use disorder.
Download Printable Copy of Blank ORT Form
ORT-1A: Family History of Substance Abuse (Alcohol)
ORT-1B: Family History of Substance Abuse (Illegal Drugs)
ORT-1C: Family History of Substance Abuse (Prescription Drugs)
ORT-2A: Personal History of Substance Abuse (Alcohol)
ORT-2C: Personal History of Substance Abuse (Prescription Drugs)
ORT-3: Age (Age 16 -45)
ORT-5A: Psychological Disease (Attention Deficit Disorder, Obsessive Compulsive Disorder, Bipolar, Schizophrenia)
ORT-5B: Psychological Disease (Depression)
Urine Drug Testing Recommendation: ask if needed here ...