PC PHARM PAIN

What    brings    you    in    today?
[textarea name="variable_1" default=""]
  Onset
	When did it begin?
	[textarea name="variable_2" default=""]
	How long does it typically last?
	[textarea name="variable_3" default=""]
	How often does it occur?
	[textarea name="variable_4" default=""]
	What were you doing when it started?
	[textarea name="variable_5" default=""]
 
  Provoking / palliating factors
	What brings it on?
	[textarea name="variable_6" default=""]
	What makes it worse?
	[textarea name="variable_7" default=""]
	What makes it better?
	[textarea name="variable_8" default=""]
 
  Quality
	What does it feel like?
    [textarea name="variable_9" default=""]
 
  Region & radiation
	Does your pain radiate?
	[textarea name="variable_10" default=""]
	Where does it radiate to?
	[textarea name="variable_11" default=""]
	Where does it hurt the most?
	[textarea name="variable_12" default=""]
	Where does your pain go from there?
	[textarea name="variable_13" default=""]
 
  Severity    /    Symptoms
	Are there any other symptoms that accompany the pain?
	[textarea name="variable_14" default=""]
 
  Timing & treatment - see below
 
  Understanding
	What do you believe is causing this?
	[textarea name="variable_15" default=""]
	Do you have any other concerns?
	[textarea name="variable_16" default=""]
	
Over    the    past    week    or    two,    what    has    your    pain    been    on    average    on    a    scale    of    0    to    10,    with    10    being    the    worst?    
[text name="variable_17" default=""]
What's    the    lowest    it's    been?    
[text name="variable_18" default=""]
What's    the    worst    it's    been?
[text name="variable_19" default=""]

SLEEP
Do    you    have    trouble    falling    asleep?
[text name="variable_20" default=""]
Do    you    have    trouble    staying    asleep?
[text name="variable_21" default=""]
Do    you    wake    during    the    night    due    to    pain?    
[text name="variable_22" default=""]
Is    your    sleep    restful?
[text name="variable_23" default=""]
Do    you    have    sleep    apnea?
[text name="variable_24" default=""]
Are    you    compliant    with    CPAP?
[text name="variable_25" default=""]

------------------    STOP-BANG Screener for OSA   -------------------
[checklist name="variable_27" value="
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?|Do you often feel tired, fatigued, or sleepy during the day?|Has anyone ever observed you stop breathing during your sleep?|Do you have or are you being treated for high blood pressure?|BMI > 35kg/m^2|Age > 50|Neck circumference > 16 in (40cm)|Male    gender"] 

Each YES response = 1 point        Low risk: 0 - 2 points
Moderate risk: 3 - 4 points        High risk: 5 – 8

High sensitivity (93%-100%) noted when using STOP-Bang questionnaire to detect moderate to severe and severe sleep disordered breathing in surgical population patients however low specificity noted at original cut-off of 3.

Recent studies indicate total scores of 5-8 have higher specificity.
----------------------------------------------------------------------------
Family    history    of    mental    health    or    substance    use    issues?
[textarea name="variable_28" default=""]

Mobility/Activity:
   Current work: [text name="variable_29" default=""]   
   General daily activities:    [text name="variable_30" default=""]
   Use of mobility aids?:    [text name="variable_31" default=""]
   Exercise    regimen:    [text name="variable_32" default=""]
   
Social:
Marital/relationship    status:
[text name="variable_33" default=""]
Social    support:
[text name="variable_34" default=""]


Caffeine    intake:
[text name="variable_35" default=""]
Alcohol    use:
[text name="variable_36" default=""]
Tobacco/nicotine    use:
[text name="variable_37" default=""]
Illicit    substances:
[text name="variable_38" default=""]
Marijuana/cannabis:
[text name="variable_39" default=""]
   
Functional Goal(s):
   What would you like to do that your pain is currently preventing you from
   doing?
   [textarea name="variable_40" default=""]
   
Surgical    history:
[textarea name="variable_41" default=""]

Any    OTCs,    vitamins,    or    supplements?
[text name="variable_42" default=""]
Any    other    non-VA    meds?
[text name="variable_43" default=""]
Any    non-VA    providers?
[text name="variable_44" default=""]

What    are    your    biggest    concerns?
Family    history    of    mental    health    or    substance    use    issues?
[textarea name="variable_45" default=""]

What    are    your    expectations?
Family    history    of    mental    health    or    substance    use    issues?
[textarea name="variable_46" default=""]
What brings you in today?

Onset
When did it begin?

How long does it typically last?

How often does it occur?

What were you doing when it started?


Provoking / palliating factors
What brings it on?

What makes it worse?

What makes it better?


Quality
What does it feel like?


Region & radiation
Does your pain radiate?

Where does it radiate to?

Where does it hurt the most?

Where does your pain go from there?


Severity / Symptoms
Are there any other symptoms that accompany the pain?


Timing & treatment - see below

Understanding
What do you believe is causing this?

Do you have any other concerns?


Over the past week or two, what has your pain been on average on a scale of 0 to 10, with 10 being the worst?

What's the lowest it's been?

What's the worst it's been?


SLEEP
Do you have trouble falling asleep?

Do you have trouble staying asleep?

Do you wake during the night due to pain?

Is your sleep restful?

Do you have sleep apnea?

Are you compliant with CPAP?


------------------ STOP-BANG Screener for OSA -------------------


Each YES response = 1 point Low risk: 0 - 2 points
Moderate risk: 3 - 4 points High risk: 5 – 8

High sensitivity (93%-100%) noted when using STOP-Bang questionnaire to detect moderate to severe and severe sleep disordered breathing in surgical population patients however low specificity noted at original cut-off of 3.

Recent studies indicate total scores of 5-8 have higher specificity.
----------------------------------------------------------------------------
Family history of mental health or substance use issues?


Mobility/Activity:
Current work:
General daily activities:
Use of mobility aids?:
Exercise regimen:

Social:
Marital/relationship status:

Social support:



Caffeine intake:

Alcohol use:

Tobacco/nicotine use:

Illicit substances:

Marijuana/cannabis:


Functional Goal(s):
What would you like to do that your pain is currently preventing you from
doing?


Surgical history:


Any OTCs, vitamins, or supplements?

Any other non-VA meds?

Any non-VA providers?


What are your biggest concerns?
Family history of mental health or substance use issues?


What are your expectations?
Family history of mental health or substance use issues?

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.02, 45 form elements, 330 boilerplate words, 23 text boxes, 21 text areas, 1 check lists, 52 total clicks
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