Follow Up Form for Pain Management

Follow Up Form

Pain Management
Patient Name*

First NameLast Name
Reason for your visit?*
CURRENT Height:
Weight:
Pain Score

Enter score based on a scale of 1 to 10.
Current pain score:
Pain score at worst:
Pain score at best:
Average pain score:
History of Present Illness:
When and how did your pain start?
What makes your pain better?
What makes your pain worse?
Since you were last seen, has your pain:

IncreasedDecreasedRemained the same
What best describes your pain:

ConstantIntermittent
When is your pain worst:

MorningDaytimeEveningNight
In the past 3 months, have you developed any of the following? Select all that apply.

Balance ProblemGroin NumbnessDifficulty walkingNew weaknessBowel IncontinenceBladder IncontinenceNew Numbness
Any Updates to your Allergies/Medical/Surgical/Psychiatric History since your last visit?
Review of Systems

Check all that apply.
Constitution

Fever/chillsWeight lossMalaise/fatigueNight sweatsWeaknessSwollen lymph nodes
Eyes

Blurred/changes to visionLight sensitivityEye painEye dischargeDry eyes
Gatrointestinal

HeartburnNausea/VomitingAbdominal painDiarrheaConstipationIncontinence of stool
Hematology

Easy brusingEasy bleedingBlood clots
Skin

RashItchingHair lossFingers turn white with cold
Cardiovascular

Chest painPalpitationsDifficult breathing when lying flatAnkle/leg swelling
Genitourinary

Painful urinationBlood urineFlank painIncontinence of urine
Neurological

DizzinessLightheadednessHeadachesTinglingTremorSensory changeSeizures
Ear/Nose/Throat

Hearing lossEar painSinus painSore throatSwollen lymph nodesDry mouthNose bleeds
Respiratory

Cough/coldSputum productionShortness of breathWheezing
Musculoskeletal

Muscle painsNeck painBack painJoint painRecent fallsLoss of height
Psychiatric

DepressionSuicidal thoughtsHallucinationsAnxietyDifficulty sleepingMemory loss
Please select the best description of your pain.

AchingBurningCrampsDullNumbnessSharpShootingStiffnessThrobbingTinglingPins & NeedlesPoundingColdHeaviness
Please describe your pain if not listed:
Signature

Powered by Jotform SignClear
Should be Empty:

Follow Up Form

Pain Score

History of Present Illness:

Review of Systems