SAMPLE INITIAL PAIN MANAGEMENT TEMPLATE
March 24, 2015
RE: _____ _____
Pain Level: (1-10 scale):
History of Present Illness: The patient presents to my office today for the first time on
consultation for pain management evaluation. History obtained is that the patient is 45
years of age, male, right-handed, no history of any known allergies, he presents with a
chief complaint of neck pain, which radiates down to the right upper extremity with
numbness and tingling in the right biceps. This happened after a motor vehicle accident,
which occurred approximately one year ago when he was a restrained driver of a vehicle
hit in the rear sustaining severe injuries to his neck. The entire rear of his car was almost
completely demolished. He was not hospitalized. He went to a local emergency room.
He was treated and released. He had x-rays of the neck, which showed no fractures. He
then treated with many different doctors, however, he has not been happy with the results
of his treatments and his pain has not been properly eradicated. Today, he presents for
continued pain management, evaluation, and treatment. He is currently not under the
care of any other doctors. He is currently taking no pain medications.
Past Medical History: No history of any psychiatric problems. No history of anxiety or
depression, no history of any suicide ideas, or attempts. No history of any alcohol or
drug abuse in the past.
Diagnostic Test Performed and its Result and the Date Performed: X-rays, MRIs,
EMGs, other. _____.
Medications: What medications and dosages have you tried in the past and what were
Current medications and dosage and its results and who has prescribed them to you?
Any recreational or illicit or over-the-counter drugs currently being used, if so what?
What treatments have you had in the past and what results were obtained? (Physical
therapy, trigger point injections, epidural injections, facet, radiofrequency ablation, dorsal
column stimulation implant).