Pain Management Follow up Subjective

Follow up for review of opioid therapy for chronic pain associated with [text name="variable_1" default=" "] for the past [text name="variable_1" default=" "] years.

HPI:
Current Analgesic Regimen (Opioids, non-opioids, adjuncts) 
Opioids: 
[text name="variable_7" default=" "]
Morphine Equiv/Day = 
[text name="variable_8" default=" "]
Non-Opioids: 
[text name="variable_9" default=" "]
Adjuncts (TCAs, Gabapentin, SSRIs): 
[text name="variable_10" default=" "]
NSAIDS: 
[text name="variable_11" default=" "]
OTCs (Capsaicin, Tylenol, glucosamine): 
[text name="variable_12" default=" "]

Review of Systems: 
GENERAL: [checkbox name="variable_7" value=" + fatigue|No fatigue|+ Wt Gain|No Wt gain|+ Wt Loss|No Wt Loss|+ Fever|No Fever|+ Chills|No Chills|+ Night sweats|No Night sweats"][text name="variable_14" default=", "]
GI: [checkbox name="variable_8" value=" + Anorexia|No anorexia|+ Constipation|No Constipation|+ Diarrhea|No Diarrhea|+ Nausea|No Nausea|+ Vomiting|No Vomiting"][text name="variable_15" default=", "]
M/S: [checkbox name="variable_9" value=" + Arthralgias|No Arthralgias|+ Back Pain|No Back Pain|+ Limb Pain|No Limb Pain|+ Myalgias|No Myalgias|+ Walker|No Walker|+ Wheelchair|No Wheelchair|+ Cane|No Cane|+ Independent Gait|No Independent Gait|+ Needs Assist|No Needs Assist|+ Non-ambulatory|+ Ambulatory|+ Self-transfers|No Self-Transfers|+ Bed bound|Not Bed Bound|+ Generalized weakness"][text name="variable_16" default=", "]
NEURO: [checkbox name="variable_10" value=" + Weakness|No Weakness|+ HA|No HA|+ Sz|No Sz|+ Tremors|No Tremors|+ Falls|No Falls|+ Hx Falls|No Hx Falls|+ Neuropathy|No Neuropathy|+ Vertigo|No Vertigo|+ Poor Balance|No Poor Balance"][text name="variable_17" default=", "]
PSYCH: [checkbox name="variable_11" value=" + Anxiety|No Anxiety|+ Depression|No Depression|+ Memory Loss|No Memory Loss|+ Insomnia|No Insomnia|+ Hypersomnolence|No Hypersomnolence|+ Psychosis|No Psychosis"][text name="variable_18" default=", "]
SKIN: [checkbox name="variable_12" value=" + Rash|No Rash|+ Pruritus|No Pruritus|+ Wounds|No Wounds|+ Infection|No Infection"][text name="variable_19" default=", "]

Functional Status
How does the patient rate their ability to perform ADLs? 
[checkbox name="variable_14" value="Excellent|Good|Fair|Poor"]
Patient satisfaction with pain treatment is: 
[checkbox name="variable_15" value="Satisfactory|Unsatisfactory"]
Patient's pain relief with the current treatment plan is (%): 
[text name="variable_29" default=" "]
Activities limited or different due to pain? 
[text name="variable_30" default=" "]
Since the last visit, the patient's pain is:
[checkbox name="variable_20" value="Improved|Stable|Diminished"]

Co-Morbidities:
During the past week, how much has pain interfered with (0 = none, 10 = maximum interference):
Sleep (0-10)? 
[text name="variable_31" default=" "]
General activities (0-10)? 
[text name="variable_32" default=" "]
Mood (0-10)? 
[text name="variable_33" default=" "]
Walking ability (0-10)? 
[text name="variable_34" default=" "]
Normal work (at home and outside) (0-10)? 
[text name="variable_35" default=" "]
Relations with other people (0-10)?
[text name="variable_36" default=" "]
Enjoyment of Life (0-10)? 
[text name="variable_37" default=" "]

The patient [select name="variable_1" value="has|has not"] been recently assessed for depression and this [select name="variable_1" value="is|is not"] currently a problem requiring therapy.
[text name="variable_38" default=" "]

Limitations of Current Therapy
The current therapy plan has the following issues which affect compliance or effectiveness: 
[checkbox name="variable_16" value="Constipation|Sedation|Cognitive|Breakthrough pain|Meds becoming ineffective"]
[text name="variable_42" default=" "] 

Non-Pharmacological Adjuncts
The patient is currently using the following adjunctive therapies to improve their functional status: 
[checkbox name="variable_17" value="None|Counseling, support groups|Stretching, massage, yoga|Exercise, aquarobics, water walking|Music, meditation, prayer|Biofeedback, relaxation, distraction|PT"]
[text name="variable_43" default=" "]

Patient Goals: 
[checkbox name="variable_18" value="Has not tried to achieve goals|Goals nearly achieved|Goals achieved|Goals exceeded|No established goals"]
After this visit, what do you want to accomplish or change to improve your pain? 
[textarea name="variable_12" default=" "]

PHQ-9 Score: [text name="variable_44" default=" "]
SOAPP Score: [text name="variable_45" default=" "]

Screening for potential aberrant drug-related behavior:
[checkbox name="variable_19" value="No aberrant behaviors noted|Requests frequent early renewals|Frequent increased dose without authorization|Reports lost/stolen prescriptions|Obtained prescriptions from other doctors/ER|Excessive focus on opiates|Multiple calls for meds/High user resources|Increasingly unkempt or impaired|Abusing alcohol or illicit drugs|Forging prescriptions|Insists on certain medication by name|Purposeful over-sedation|Negative mood change|Involvement in car or other accident|If aberrant behaviors noted consider referral to Substance Abuse Program for further assessment"]