Pain Management Initial Visit Subjective:

Visit Type: [checkbox name="variable_70" value="Pain Management|ALF|ILF|Home"]

HPI:
[textarea name="variable_2" default=""]
Severity now (0-10): [text name="variable_38" default=" "]
Pain goal (0-10): [text name="variable_39" default=" "]
Severity at best (0-10): [text name="variable_1" default=" "]
Severity at worst (0-10):[text name="variable_2" default=" "]
Pain range in the last week: [text name="variable_3" default=" "]
Is this better, stable or worse than 6 months ago:[checkbox name="variable_6" value="Better|Stable|Worse"]

Current Analgesic Regimen (Opioids, non-opioids, adjuncts)
Opioids: [text name="variable_7" default=" "]
Morphine Equiv/Day = [text name="variable_8" default=" "]

Non-Opioids:
Adjuncts (TCAs, Gabapentin, SSRIs): [text name="variable_10" default=" "]
NSAIDS: [text name="variable_11" default=" "]
OTCs (Capsaicin, Tylenol, glucosamine): [text name="variable_12" default=" "]

Bowel Regimen: [text name="variable_82" default=" "]

Review of Drug Allergies: [text name="variable_13" default=" "]

Functional Status
Review of ADLs: [checkbox name="variable_5" value="Independent grooming/personal hygiene|Needs assistance with grooming/personal hygiene|Independent dressing|Needs assistance dressing|Independent toileting|Needs assistance toileting|Independent transferring/ambulating|Needs assistance transferring/ambulating|Independent eating|Needs assistance eating"]
Is this better, stable or worse than 6 months ago: [checkbox name="variable_6" value="Better|Stable|Worse"]
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 current treatment plan is (%): [text name="variable_29" default=" "]

Activities limited or different due to pain? [text name="variable_30" default=" "]

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=" "]

Past Medical History
Geriatric Depression Scale: [text name="variable_90" default=" "]
The patient [select name="variable_1" value="has|has not"] been recently assessed for depression and this [select name="variable_2" value="is|is not"] currently a problem requiring therapy. [text name="variable_38" default=" "]

SLUMS: [text name="variable_90" default=" "]

Get Up and Go Test: [text name="variable_90" default=" "] [checkbox name="variable_91" value="Patient takes 12 or more seconds to complete (increased risk of fall)|Patient takes less than 12 seconds to complete (WNL)|Patient unable to complete due to physical limitations"]
Review of previous drug use history: Reviewed 
[textarea name="variable_7" default=""]

Review of previous diagnostic studies (Imaging and Labs): Reviewed
[textarea name="variable_8" default=""]

Review of previous interventions and results (including non-pharm therapies ie PT, acupuncture, biofeedback): [textarea name="variable_9" default=" "]

Past Surgical History: Reviewed
[textarea name="variable_10" default=" "]

Tobacco use: [checkbox name="variable_13" value="Non-Smoker|Current Smoker|Former Smoker"]
ETOH Use: [text name="variable_20" default=" "]
Recreational drug use: [text name="variable_21" default=" "]
Past history of drug or alcohol abuse: [text name="variable_22" default=" "]
Exercise: [text name="variable_23" default=" "]
Nutrition/Weight: [text name="variable_24" default=" "]
Psychosocial/Environmental Factors: [text name="variable_25" default=" "]
Education: [text name="variable_26" default=" "]
Occupation: [text name="variable_27" default=" "]
Marital Status/Support: [text name="variable_28" default=" "]

Limitations of Current Therapy
What drug side effects or symptoms are you having? [checkbox name="variable_16" value="Constipation|Sedation|Cognitive|Breakthrough pain|Meds becoming ineffective|None"][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=" "]

The current therapy plan has the following issues which affect compliance or effectiveness: [textarea name="variable_11" default=" "]

Patient Goals
After this visit, what do you want to accomplish or change to improve your pain? 
[textarea name="variable_12" default=""]

SOAPP Screening
[select name="Q10" value="Never (0 points)=0|Seldom (1 point)=1|Sometimes (2 points)=2|Often (3 points)=3|Very often (4 points)=4"] <-- #1 How often do you have mood swings?
[select name="Q11" value="Never (0 points)=0|Seldom (1 point)=1|Sometimes (2 points)=2|Often (3 points)=3|Very often (4 points)=4"] <-- #2 How often do you smoke a cigarette within an hour after
you wake up?
[select name="Q12" value="Never (0 points)=0|Seldom (1 point)=1|Sometimes (2 points)=2|Often (3 points)=3|Very often (4 points)=4"] <-- #3 How often have you taken medication other than the way that it was prescribed?
[select name="Q13" value="Never (0 points)=0|Seldom (1 point)=1|Sometimes (2 points)=2|Often (3 points)=3|Very often (4 points)=4"] <-- #4 How often have you used illegal drugs (for example,
marijuana, cocaine, etc.) in the past five years?
[select name="Q14" value="Never (0 points)=0|Seldom (1 point)=1|Sometimes (2 points)=2|Often (3 points)=3|Very often (4 points)=4"] <-- #5 How often, in your lifetime, have you had legal problems or been arrested?
Score --> [calc value="score=(Q10)+(Q11)+(Q12)+(Q13)+(Q14)" memo="score"] out of 20 points.
Interpretation --> [calc value="score=(Q10)+(Q11)+(Q12)+(Q13)+(Q14);score<4?'Minimal relative risk for developing problems when placed on long-term opioid therapy':score>=4?'Increased relative risk for developing problems when placed on long-term opioid therapy':score>35?'Mild':score>30?'Minimal Symptoms':'Asymptomatic'" memo="interpretation"]

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"]

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=", "]

Past medical history---REVIEWED
Allergies---REVIEWED
Medications---REVIEWED.