Pain Management

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How Stealth Health WorksA short message from our CMO
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Email* This field is required.
example@example.com
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Medication 1
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Medication 2
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Dosage Instructions
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Quantity
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Repeats
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Please enter a promo code if you have one (Optional)Please enter it here
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Where do you experience pain?Please select all that apply.
Jaw
Upper Back
Neck
Lower Back
Shoulder
Elbow
Wrist
Hand
Thumb
Fingers
Chest
Pelvis
Hip
Thigh
Knee
Ankle
Foot
Toes
Other
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Please Specify:
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How long have you had the pain?
A few hours
A day
A few days
A week
A few weeks
A month
Several months
A year
Several years
Other
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Please Specify:
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How has your pain been this week?
Much better
The same
Better
Worse
Much worse
Variable
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What have you tried to manage your pain in the past?
Surgery
Prescription Medication
Supplements/Over the counter products
Counselling/Therapy
Exercise
Other
None
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Please specify:
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How severe is the pain from 0-10 (0=no pain, 10=worse pain)?
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How would you describe the pain?
Dull
Sharp
Aching
Burning
Electrical
Lightning-like
Other
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Please specify:
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What makes your pain worse?
Light activity
Prolonged activity
Rest
Sitting down
Standing
Walking
All types of motion
Other
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Please specify:
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Have you ever had any of the following symptoms?
Fever
Joint swelling
Fatigue
Difficulty gripping onto objects
Stiffness
Morning stiffness lasting more than an hour
None
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Do you have a history of any of the following?
Hypersensitivity to NSAIDs
Heart failure, heart attack, or cardiovascular disease/impairment
Bleeding disorders
Severe liver impairment
Urinary or renal impairment
Hyperkalemia
Stroke
Ulcers
Cerebrovascular disease or dementia
Hypertension
Epilepsy/Convulsive disorders
Respiratory impairment
Neuromuscular disorders
None
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Have you been diagnosed with hormonal imbalance?
YESNO
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Are you taking any of the following medications?
Antidepressants
Lithium
MAO inhibitors
Antihypertensives
Levodopa/DDC
Antidiabetic agents
Neuromuscular blocking agents
None
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Is your pain located in an area where you have open wounds or broken skin?
YESNO
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What is your pain preventing you from?
Playing sports
Running
Walking
Climbing stairs
Kneeling
Doing routine activities around the house
Sleeping
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Please specify:
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Do you have any mental health diagnoses?
YESNO
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If yes, please specify:
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Have you had a blood test in the past year?
YESNO
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Was anything abnormal with the blood test? (Liver enzymes, INR, etc.?)
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How often do you consume alcohol?
Please Select
Please Select
Rarely/Never
Sometimes
Frequently
Always
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How often do you consume alcohol?
Rarely/Never
Sometimes
Frequently
Daily/Always
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Have you used any of the following substances in the past six months?
Cocaine
Methamphetamine
Opioids
Cannabis
None
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Do you smoke?
YESNO
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How often do you smoke? (Packs a week, etc.)
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Are you using any nicotine replacement products?
YESNO
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If yes, please explain:
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Do you have any concerns about potential side effects of pain management treatments?
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Ok
Ok
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Is there anything else you would like to share with the healthcare team?
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Ok
Ok
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
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Date of Birth
Year, Month, Day
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Biological Sex
Male
Female
Intersex
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Are you currently pregnant or breast feeding?
YESNO
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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Algeria
American Samoa
Andorra
Angola
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Antigua and Barbuda
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Aruba
Australia
Austria
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Bahrain
Bangladesh
Barbados
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Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
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Ghana
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Greece
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Mali
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Northern Mariana
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Palau
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Paraguay
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Portugal
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eSwatini
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Taiwan
Tajikistan
Tanzania
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Timor-Leste
Togo
Tokelau
Tonga
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Tristan da Cunha
Tunisia
Turkey
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Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Allergies?
YESNO
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What is your allergy?
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Ok
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Are you currently taking any medications, vitamins, herbs, or supplements?
YESNO
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Please list your medications, vitamins, herbs, and supplements here:(Name, Strength, Regimen)
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Ok
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Do you have any medical conditions?
YESNO
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Please list your medical conditions here:(Name, How long you've had the condition)
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Ok
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SignatureBy signing below you accept that the above information provided is accurate and truthful. You also acknowledge that a staff member will contact you for ID verification prior to dispensing the prescription.
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