Musculoskeletal & Rheumatology
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Consultation Date:
Patient’s name:
Date birth:

Dear Dr. [text name="variable_1" default="Doctor name"]
Thank you for referring this [text name="variable_2" default="Age"] years old [select name="variable_3" value="right|left"] handed [select name="variable_4" value="lady|gentleman"] to pain care Clinic St.Catherine site for chronic pain assessment and management.
HISTORY OF PRESENTING COMPLAINT/S
[select name="variable_5" value="His|Her"] main complaint is [text name="variable_6" default="complaint"]. The pain resulted from [text name="variable_8" default="cause of pain"].[select name="variable_497" value="He|She"] has had this pain for the past [text name="variable_7" default="years,months.."] and reports symptoms of pain described as [select name="variable_8" value="combination of nociceptive and neuropathic|nociceptive|neuropathic"] pain with characters of [checkbox name="variable_9" value="Dull|Achy|Constant|Sharp|Shooting|Burning|Tingling|Cramping|Numbness"]. DN4 Score [select name="variable_10" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"]
On an NRS scale the pain rating is [select name="variable_11" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at its worst, [select name="variable_12" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] at best. on average it is [select name="variable_13" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"] and currently the pain is [select name="variable_14" value="0/10|1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10"]. Total BPI Interference Score is [text name="variable_15" default="/70"]
Pain radiate to [text name="variable_16" default="pain radiation"]
symptoms are worsened by [text name="variable_17" default="worsen by"] and relieved by [text name="variable_18" default="relieved by"]
The patient is also complaining of [text name="variable_19" default="any other pain"].

Fibromyalgia Rapid Screening Tool: [select name="variable_20" value="Form not filled|0/6|1/6|2/6|3/6|4/6|5/6|6/6"] , [select name="variable_21" value="is suggestive of|Not suggestive of|that can be helpful"] for diagnosis of fibromyalgia.
[checkbox name="variable_22" value="With respect to the patient’s complaint of back pain, the patient reports no bowel or bladder dysfunction. There is no saddle anaesthesia, weakness or radiation reported. No thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient denies overt trauma, I.V. drug use, chronic steroid use or substantive night pain.|With respect to the patient’s complaint of neck pain the patient reports no paresthesia, weakness or radiation. No thoracic pain, fever, weight loss, night sweats, immunosuppression or history of carcinoma. The patient denies overt trauma, I.V drug use, chronic steroid use or substantive night pain.|The patient’s headache is not associated with nausea, vomiting, photophobia, or phonophobia. There are not reported visual changes or aura. No history of syncope, seizure or head injury. No fever/chills or signs of systemic infection. No history of hypertension. There are no indications of medication overuse headache."]

CONSULTATIONS and Other Healthcare Professionals: [textarea name="variable_23" default="past consultations"]
[select name="variable_130" value="He|She"] has done physical therapy in past such as [checkbox name="variable_24" value="no physical treatment in past|Physiotherapy|Acupuncture|Chiropractic care|Massage therapy|Tai Chi|Aquatic exercises"][text name="variable_498" default="others"]
PAST MEDICAL HISTORY
1. Surgical:[text name="variable_25" default="surgical PMH"]
2. Medical:[text name="variable_26" default="Medical PMH"]
FUNCTONAL INQUIRY

..........................................
Constitutional Symptoms:
[checkbox name="variable_100" value="Fatigue|Recent weight loss/gain|Recurring fever|Eye disease or injury|Wear glasses/contact|Blurred/double vision|Glaucoma|Hearing loss or ringing|Ear infection/drainage|Chronic sinus problem|Nosebleeds|Mouth sores|Bleeding gums|Hoarseness|Swollen glands in neck"]
Cardiovascular:
[checkbox name="variable_101" value="Chest pain|Heart attack|Palpitations|Swelling of feet, hands, ankles|Rheumatic fever|Heart valve replacement|High blood pressure|Low blood pressure|Mitral valve prolapse|Heart Murmur|High cholesterol|Pace maker"]
Respiratory:
[checkbox name="variable_102" value="CHronic or frequent cough|Spitting up blood|Shortness of breath|Asthma or Wheezing|Tuberculosis|Emphysema|Pulmonary Disease|Sleep Apnea|If yes use breathing machine|Use home oxygen"]
Gastrointestinal
[checkbox name="variable_103" value="Loss of appetite|Nausea/Vomitting|Frequent diarrhea|Constipation|Rectal Bleeding|Abdominal pain|Stomach ulcer/heartburn|Hepatitis|Cirrhosis|Pancreatitis"]
Genitourinary
[checkbox name="variable_104" value="Renal|Frequent urination|Burning or painful urination|Blood in urine|Sexually transmitted disease|Prostate disease"]
Musculoskeletal:
[checkbox name="variable_105" value="Arthritis degenertive|Arthritis, rheumatoid|Joint pain|Weakness of muscle/joints|Muscle pain or cramps|Back pain|Cold extremities|Difficulty walking|Muscular dystrophy|Osteoporotsis|Joint replacement|Fibromyalgia"]
Skin:
[checkbox name="variable_106" value="Rash/itching|Change in skin colour|Change in hair|Hives|Psoriasis"]
Psychiatric:
[checkbox name="variable_107" value="Alzheimer's disease|Memory loss/confusion|Depression|Sucidal thoughts|Chemical dependency"]
Neurological:
[checkbox name="variable_108" value="Frequent/recurring headaches|Migraines|Light headed/dizzy|Convulsions/seizures|Numbness or tingling|Paralysis|Stroke|Head injury|Polio|Multiple sclerosis|Cerebral Palsy"]
Endocrine:
[checkbox name="variable_109" value="Diabetes|Insulin Dependent|Non INsulin Dependent/Diet Controlled?|Thyroid disease|Glandular/hormonal prob|Excessive thirst or urination"]
Hematologic/Iymphatic:
[checkbox name="variable_110" value="Slow to heal after cuts|Bleeding or bruising|Anemia|Phlebitis/blood clots|Past transfusions|Leukemia|Lymphoma|HIV/AIDS|Sickle cell|Cancer|Radiation Treatment"]

General functional inquiry including cardiovascular, respiratory, gastrointestinal, genitourinary, haematological and endocrine systems was unremarkable at the moment. No other musculoskeletal or neurological issues were reported other than the chief complaints.
PREVIOUS INVESTIGATIONS
X-rays:[textarea name="variable_27" default="X-ray"]
CT: [textarea name="variable_28" default="CT Scan"]
MRI: [textarea name="variable_29" default="MRI"]
U/S: [textarea name="variable_30" default="Ultrasound"]
Other:[textarea name="variable_31" default="Other tests"]

PAST PAIN MEDICATIONS
[textarea name="variable_32" default="Past PAIN Meds"]
CURRENT MEDICATIONS [text name="variable_499" default="sample text"]
The patient’s current narcotic dose is [text name="variable_32" default="number"] MED. This [select name="variable_33" value="Exceeds|Falls"] within the NOUGG.
ALLERGIES
Medications: [text name="variable_34" default="NKDA"]
Environmental:[text name="variable_35" default="Nill"]
SOCIAL HISTORY
The patient is currently [checkbox name="variable_36" value="single|married|widow|common law|divorced"] and is
Presently living [text name="variable_37" default="alone,with family..."]. The patient has [select name="variable_38" value="no|1|2|3|4|5|6|7"] children, [text name="variable_39" default="."] [select name="variable_40" value="He|She"] is currently working as [text name="variable_41" default="job"].
He/She is Currently on Disability and has been so since …………… Patient is currently unemployed and has been so since ……….. the patient is retired. The patient’s highest level of education completed is high school/college/university. He/She has a diploma/degree in

PSYCHOLOGICAL STATUS AND RELATED MATTERS
There is no history of suicidal ideation and the patient has had no previous suicide attempts. The current suicide risk is low moderate high. The patient does not see a psychiatrist.
Hamilton Depression Rating Scale (HAM-D): ……………./45
(0-7 = Normal
8-13 = Mild Depression
14-18 = Moderate Depression
19-22 = Severe Depression
>23 = Very Severe Depression)
Sexual function is reportedly unimpaired. Sexual function is adversely affected; both desire and physical ability are reduced by pain/medication. He/She is un/concerned about this issue.
Sleep is generally unrefreshing. There is latency in sleep onset with frequent interruptions due to the pain. The patient reports awakening every ……. Hours. Medication is/isn’t utilized as a sleep aid.
ADDICTION RISK
1. Worsening AM pain: Yes No
2. Maximum ETOH SD /24 hr /7d
3. Nicotine Yes No. PPD
4. Prescription drugs: Off the street: Yes No. Borrowed: Yes No.
5. Family psychiatric history: Mother: Yes No; Father: Yes No; Siblings: Yes No; Patient adopted: Yes No
6. Family History of substance abuse:
7. History of trauma: Emotional: Yes No; Physical; Yes No; Sexual; Yes No
8. Which of the following recreational or street drugs has the patient used? None
9. Has the patient ever received treatment for drug abuse? Yes No.
a. If yes, was it residential? Yes No.
b. Where:
c. Number of times:
d. AA: NA:
10. UDS: OXY Pos/Neg TCA: Pos/Neg AMP: Pos/Neg MOP:Pos/Neg BZO: Pos/Neg
MTD: Pos/Neg BAR: Pos/Neg MAMP:Pos/Neg COC: Pos/Neg THC: Pos/Neg
11. Opiate Risk Tool: Low Risk Medium Risk High Risk
PHYSICAL EXAMINATION
Age: ….. BP ……. HR …….. Weight: …….O2 saturation ……….
On physical exam today, I found the patient to be alert, cooperative and well oriented to person, place and time. communication skills, recent and remote memory, insight and judgment, affect and mood appeared within normal limits, was able to follow commands and cooperated with the examination. Body Type is normal and appears well conditioned. Gait and posture within acceptable range.
My objective findings as related to her injuries are as follows:


IMPRESSION
………


Treatment Plan:

1. Patient treatment is considered in three domains: interventional, pharmacological, and patient-centric recommendations. With this in mind the following recommendations are suggested:

1. Patient-centric Recommendations:
a. Psychiatric referral is/not indicated at this time.
b. Your patient was been referred to the Chronic Pain Self-Management program. This program is free of charge and runs two hours per week for six weeks. It focuses on assisting patients on improving self-awareness with pain perceptions and subsequent actions. Your patient has been given further information regarding the program.
c. I recommend the patient initiate a weight loss program and increase physical conditioning with an emphasis on core strength. I have discussed the role of aqua therapy, yoga, Tai chi, and cardiovascular fitness with your patient. To assist your patient with this you may elect to refer them to physiotherapy for assessment and care.
2. Interventional Options:
I recommend a trial of nerve blocks/epidural injections for ….................. The palliative nature of these blocks was explained to the patient. The patient appeared to understand and wishes to proceed with this therapy. The patient was reluctant to consider this option; we will remain available to trial this option should they have a change of opinion.
3. Pharmacological Options (List all medication options suggestions separately and how they will be implemented):
a. (Example, I suggest a trial of Hyrdomorph Contin 3mg po q12h initially, this may be titrated further base on the patients responses and functional improvement. I have provided a prescription for 28 tablets).
The general side effects, possible interactions, and potential adverse effects of …...... was/were discussed with the patient. The patient appeared to understand and wishes to proceed with this pharmacological therapy.
(For certain medication options) The medication …............... is deemed off-label, the potential adverse effects of ….................... was/were discussed with the patient. The patient appeared to understand and wishes to proceed with this pharmacological therapy.

Once your patient appears to be stable on a treatment regimen, they will be repatriated back to you for ongoing prescriptions. At that time of they are on a narcotic analgesic, it is recommended you follow the NOUGG prescribing guidelines. I will remain available to see them for counselling and further recommendations as indicated.
Thank you for the opportunity of participation in your patient’s care, I will be seeing him/her shortly in follow-up. Should you have any questions, please do not hesitate to contact me at this Clinic.
With kind regards,
Dr. Omid Liaghati
Chronic Pain Management

ADDENDUM
Please Note: The assessment, diagnosis and opinions in this report reflect medical documentation specifically intended for medical treatment purposes only. This report does not constitute nor is it intended to be used as a functional, residual or impairment disability evaluation or other legal instruments.
Consultation Date:
Patient’s name:
Date birth:

Dear Dr.
Thank you for referring this years old handed to pain care Clinic St.Catherine site for chronic pain assessment and management.
HISTORY OF PRESENTING COMPLAINT/S
main complaint is . The pain resulted from . has had this pain for the past and reports symptoms of pain described as pain with characters of . DN4 Score
On an NRS scale the pain rating is at its worst, at best. on average it is and currently the pain is . Total BPI Interference Score is
Pain radiate to
symptoms are worsened by and relieved by
The patient is also complaining of .

Fibromyalgia Rapid Screening Tool: , for diagnosis of fibromyalgia.


CONSULTATIONS and Other Healthcare Professionals:
has done physical therapy in past such as
PAST MEDICAL HISTORY
1. Surgical:
2. Medical:
FUNCTONAL INQUIRY

..........................................
Constitutional Symptoms:

Cardiovascular:

Respiratory:

Gastrointestinal

Genitourinary

Musculoskeletal:

Skin:

Psychiatric:

Neurological:

Endocrine:

Hematologic/Iymphatic:


General functional inquiry including cardiovascular, respiratory, gastrointestinal, genitourinary, haematological and endocrine systems was unremarkable at the moment. No other musculoskeletal or neurological issues were reported other than the chief complaints.
PREVIOUS INVESTIGATIONS
X-rays:
CT:
MRI:
U/S:
Other:

PAST PAIN MEDICATIONS

CURRENT MEDICATIONS
The patient’s current narcotic dose is MED. This within the NOUGG.
ALLERGIES
Medications:
Environmental:
SOCIAL HISTORY
The patient is currently and is
Presently living . The patient has children, is currently working as .
He/She is Currently on Disability and has been so since …………… Patient is currently unemployed and has been so since ……….. the patient is retired. The patient’s highest level of education completed is high school/college/university. He/She has a diploma/degree in

PSYCHOLOGICAL STATUS AND RELATED MATTERS
There is no history of suicidal ideation and the patient has had no previous suicide attempts. The current suicide risk is low moderate high. The patient does not see a psychiatrist.
Hamilton Depression Rating Scale (HAM-D): ……………./45
(0-7 = Normal
8-13 = Mild Depression
14-18 = Moderate Depression
19-22 = Severe Depression
>23 = Very Severe Depression)
Sexual function is reportedly unimpaired. Sexual function is adversely affected; both desire and physical ability are reduced by pain/medication. He/She is un/concerned about this issue.
Sleep is generally unrefreshing. There is latency in sleep onset with frequent interruptions due to the pain. The patient reports awakening every ……. Hours. Medication is/isn’t utilized as a sleep aid.
ADDICTION RISK
1. Worsening AM pain: Yes No
2. Maximum ETOH SD /24 hr /7d
3. Nicotine Yes No. PPD
4. Prescription drugs: Off the street: Yes No. Borrowed: Yes No.
5. Family psychiatric history: Mother: Yes No; Father: Yes No; Siblings: Yes No; Patient adopted: Yes No
6. Family History of substance abuse:
7. History of trauma: Emotional: Yes No; Physical; Yes No; Sexual; Yes No
8. Which of the following recreational or street drugs has the patient used? None
9. Has the patient ever received treatment for drug abuse? Yes No.
a. If yes, was it residential? Yes No.
b. Where:
c. Number of times:
d. AA: NA:
10. UDS: OXY Pos/Neg TCA: Pos/Neg AMP: Pos/Neg MOP:Pos/Neg BZO: Pos/Neg
MTD: Pos/Neg BAR: Pos/Neg MAMP:Pos/Neg COC: Pos/Neg THC: Pos/Neg
11. Opiate Risk Tool: Low Risk Medium Risk High Risk
PHYSICAL EXAMINATION
Age: ….. BP ……. HR …….. Weight: …….O2 saturation ……….
On physical exam today, I found the patient to be alert, cooperative and well oriented to person, place and time. communication skills, recent and remote memory, insight and judgment, affect and mood appeared within normal limits, was able to follow commands and cooperated with the examination. Body Type is normal and appears well conditioned. Gait and posture within acceptable range.
My objective findings as related to her injuries are as follows:


IMPRESSION
………


Treatment Plan:

1. Patient treatment is considered in three domains: interventional, pharmacological, and patient-centric recommendations. With this in mind the following recommendations are suggested:

1. Patient-centric Recommendations:
a. Psychiatric referral is/not indicated at this time.
b. Your patient was been referred to the Chronic Pain Self-Management program. This program is free of charge and runs two hours per week for six weeks. It focuses on assisting patients on improving self-awareness with pain perceptions and subsequent actions. Your patient has been given further information regarding the program.
c. I recommend the patient initiate a weight loss program and increase physical conditioning with an emphasis on core strength. I have discussed the role of aqua therapy, yoga, Tai chi, and cardiovascular fitness with your patient. To assist your patient with this you may elect to refer them to physiotherapy for assessment and care.
2. Interventional Options:
I recommend a trial of nerve blocks/epidural injections for ….................. The palliative nature of these blocks was explained to the patient. The patient appeared to understand and wishes to proceed with this therapy. The patient was reluctant to consider this option; we will remain available to trial this option should they have a change of opinion.
3. Pharmacological Options (List all medication options suggestions separately and how they will be implemented):
a. (Example, I suggest a trial of Hyrdomorph Contin 3mg po q12h initially, this may be titrated further base on the patients responses and functional improvement. I have provided a prescription for 28 tablets).
The general side effects, possible interactions, and potential adverse effects of …...... was/were discussed with the patient. The patient appeared to understand and wishes to proceed with this pharmacological therapy.
(For certain medication options) The medication …............... is deemed off-label, the potential adverse effects of ….................... was/were discussed with the patient. The patient appeared to understand and wishes to proceed with this pharmacological therapy.

Once your patient appears to be stable on a treatment regimen, they will be repatriated back to you for ongoing prescriptions. At that time of they are on a narcotic analgesic, it is recommended you follow the NOUGG prescribing guidelines. I will remain available to see them for counselling and further recommendations as indicated.
Thank you for the opportunity of participation in your patient’s care, I will be seeing him/her shortly in follow-up. Should you have any questions, please do not hesitate to contact me at this Clinic.
With kind regards,
Dr. Omid Liaghati
Chronic Pain Management

ADDENDUM
Please Note: The assessment, diagnosis and opinions in this report reflect medical documentation specifically intended for medical treatment purposes only. This report does not constitute nor is it intended to be used as a functional, residual or impairment disability evaluation or other legal instruments.
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