Pain Management Follow Up Evaluation

FOLLOW UP EVALUATION
9816 Winchester Rd, Front Royal, VA 22630 | 11885 Holly Lane Suite 4, Waldorf, MD 20601 7700 Little River Turnpike Suite 104 Annandale, VA 22003 | 8551 Rixlew Lane Suite #140 A, Manassas, VA 20109
Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
Age*
Sex*

MaleFemale
Name*

First NameMiddle NameLast Name
Phone Number*
Email(Optional)
example@example.com
ABOUT YOUR PAIN (Chief Compliant)
What is the main problem for which you are seeking treatment at the Pain Management Center?*
PAIN LOCATIONS
Please mark the location(s) of your pain on the diagrams below. If whole areas are painful, please shade in the painful area.
ONSET OF PAIN AND DURATION
When did your current pain start?*
Briefly describe how your current pain started?*
TIMINGS OF PAIN
How often do you have your pain (please check one)?*

Constantly (100% of the time)Frequently (75% of the time)Intermittently (50% of the time)Occasionally (25% of the time)
PAIN QUALITY
How would you describe the pain (choose as many adjectives as are applicable)*

burningsharpcuttingthrobbingcrampingnumbnessdull, achingpressurepins and needlesshootingelectric-likeother
RATE YOUR PAIN INTENSITY
Please tick the one number that best describes your pain right now*

012345678910
Please circle the one that best describes your pain on average over the last week*

012345678910
Percent overall improvement since coming to the ALTMED Medical Center*
In the past week, how much RELIEF have your current pain treatments or medications provided. Please tick the one percentage that best describes how much.*

0%10%20%30%40%50%60%70%80%90%100%
CURRENT MEDICATIONS:
Patients will be a given current medication sheet to fill out or update. If you have not received a current medication sheet, please request one at the front desk of the clinic
PAST, FAMILY AND HISTORY
List activities (chores, exercise, walking longer distance, shopping, housework, etc.) you CAN DO NOW that you couldn’t do before being referred to the pain clinic. Write ‘Nothing New’ if you cannot do anything more since being referred to the pain clinic. List Activities:
Are you taking opioid medications? (morphine, Oxycontin, Vicodin, Norco, Percocet, etc.)*

NoYes
If so, do these medications increase your level of function?*

NoYes
List Activities that have increased?
Signature*

Clear
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FOLLOW UP EVALUATION

ABOUT YOUR PAIN (Chief Compliant)

PAIN LOCATIONS

ONSET OF PAIN AND DURATION

TIMINGS OF PAIN

PAIN QUALITY

RATE YOUR PAIN INTENSITY

CURRENT MEDICATIONS:

PAST, FAMILY AND HISTORY