Sample Initial Pain Management Template (Page 2 of 3) in pdf

Sample Initial Pain Management Template Page 2

RE: _______

March 24, 2015

Page 2

Current Disability Status: Partially disabled, total disabled, not disabled at all.

Social History: Single, married, do smoke cigarettes, if so how much. Do you consume

alcohol socially or recreationally and if so, how much alcohol do you consume per day or

per week.

Any history of alcohol or drug abuse currently or in the past, if so please explain.

Family History: Any family history of drug or alcohol abuse in the past, any family

history of suicide ideas or attempts in the past if so, please explain.

Educational Level: Did you finish high school, college, or business school.

Review of Systems:

Physical Examination:

Appearance: The patient appears in mild distress secondary to pain. No visible signs of

any withdrawal.

Vital Signs: Blood pressure _____, pulse _____, respiration _____.

HEENT: _____

Lungs: _____

COR:

Skin: No visible lesions. No areas of erythema. No areas of rash or any other skin

disorder.

Extremities: Without cyanosis, clubbing, or edema.

Pulses: All pulses are intact and normal.

Neck:

Back:

Active range of Motion:

Manual Muscle Power Testing: _____

Sensation: _____

Deep Tendon Reflexes: _____

Gait: _____

Diagnosis:

Treatment Plan:

1. Obtain full pertinent and past medical records.

2. Refer the patient for basic chemistry profile, urine drug toxicology screen, saliva drug

toxicology screen, CBC, basic chemistry profile, liver function tests. Other:

3. Refer the patient for additional studies such as

4. New York State Prescription monitoring program was checked and the results are

_____.

5. The patient referred to other consultant _____ for _____.

Sample Initial Pain Management Template Page 2