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

Sample Initial Pain Management Template Page 3

RE: _______

March 24, 2015

Page 3

6. The patient to be started on the course of physical therapy due to medical necessity

and goals to diminish pain, spasm, improve range of motion, improve flexibility and

conditioning, and to prevent further deterioration.

7. The patient to be reexamined in number of weeks _____.

8. Opiate agreement discussed with the patient, the patient educated in great detail about

opiate, its proper use and New York State Law governing its proper use, opiates

agreement signed after full discussion and patient education given.

9. The patient fully educated on all of his diagnoses, all the different treatment plans,

surgery, physical therapy, acupuncture, and different interventional pain management

procedures.

10. Medications prescribed and all its risks, side effects, and alternatives thoroughly

explained to the patient. _____.

Opiate Index: Very low, low, moderate, high, very high.

________________________

John Doe, M.D.

JD: ka

13-00997648.doc

Sample Initial Pain Management Template Page 3