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Pain Management
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Initial Consultation
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P
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T
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GA
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Gait
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Skin
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HEENT
• • •
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Chest: Clear
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COR: RRR S1/S2
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ABDOMEN: S/NT + BS
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NEURO
• • •
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CNI
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EXT: No C/C/E
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Shoulder/elbow/wrist
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Hip/knee/ankle
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SENSORY
• • •
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MOTOR
• • •
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L-SPINE
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THORACIC SPINE
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C-SPINE
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LUMBAR
• • •
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CERVICAL
• • •
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Midline Tenderness
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FACET JOINTS
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L
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T
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C
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LUMB: TENDERNESS (+/-)
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LUMB: CHALLENGE (+/-)
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R/L
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Paraspinal Myotonus
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THOR: TENDERNESS (+/-)
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THOR: CHALLENGE (+/-)
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R/L
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Paraspinal Myotonus
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CERV: TENDERNESS (+/-)
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CERV: CHALLENGE (+/-)
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R/L
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Paraspinal Myotonus
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DTR
• • •
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SLR
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FABER
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SIJ
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TROCHANTERIC
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SCIATIC NOTCH
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X-RAYS/MRI/CT
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EMG/NOV
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Assessment/Plan Suggested
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Location of pain or other symptoms:
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On Diagram indicate pain location
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Type of pain or symptom
• • •
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Pain Intensity
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Location of Pain
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Other Related Symptoms
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What Makes Pain Better/Worse
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Pain Hx, When,How did pain begin? has it changed
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Procedures and Medications tried in the Past
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Previous Pain Doctor
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What are your Goals
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What would you do if your pain decreased
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Med. Reactions/Allergies
• • •
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1. Substance
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Reaction
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2. Substance
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Reaction
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3. Substance
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Reaction
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4. Substance
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Reaction
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Anticoagulant Medications
• • •
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Other
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Antiplatelet Medications
• • •
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Other
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Have you ever had?
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Aids/HIV Positive
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Anemia
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Anxiety/Depression
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Arthritis
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Asthma
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Bleeding Disorders
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Cancer/Lymphoma/Leukemia
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Glaucoma
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Diabetes
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Peripheral Vascular Disease
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Emphysema/Bronchitis
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Epilepsy
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Gall Bladder Disease
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Coronary Artery Disease
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Heart Valve Disease
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Hepatitis/Liver Disease
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High Blood Pressure
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High Cholesterol
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Kidney Disease
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Migraines/Headaches
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Osteoporosis
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Psychiatric/Emotional Problems
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Sickle Cell Trait or Disease
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Ulcers/Gastroesaphogeal Reflux
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Stroke
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Thyroid Disease/Other Gland Problems
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Tuberculosis/recent infections/Hx MRSA
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Blood Clots/Bleeding Disorders
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Hospitalization
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Other
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Surgical History:
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List type of Surgery & Year Performed:
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None
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1.
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2.
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3.
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4.
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5.
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6.
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7.
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8.
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9.
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Hospital Admissions:
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List Non-surgical Hospitalization & Reason:
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None
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1.
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2.
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3.
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4.
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5.
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6.
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7.
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8.
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9.
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Social History
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Presently Employed
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Occupation or Previous Occupation
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Tobacco Use
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Packs per day
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No. of Years
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Marital Status
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Children
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Alcohol Use
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How Often (amount/type)
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Street Drugs
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Review of Systems:
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Skin
• • •
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Other
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Hematologic
• • •
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Other
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HEENT
• • •
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Other
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Neurologic
• • •
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Other
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Cardiovascular
• • •
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Other
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Gastrointestinal
• • •
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Other
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Urinary
• • •
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Other
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OB/GYN
• • •
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Other
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Endocrine
• • •
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Other
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Immunological
• • •
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Other
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Pulmonary
• • •
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Other
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Musculoskeletal
• • •
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Other
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Body Piercing
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Where
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Prosthesis
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Where
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Family History:
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Anyone in your family has any of the following?
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Birth Defects
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Family Member
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Birth Defects
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Family Member
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Cancer(Breast, Ovarian, Colon)
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Family Member
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Diabetes
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Family Member
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Heart Attack before age of 50
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Family Member
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Heart Disease
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Family Member
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High Blood Pressure
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Family Member
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High Cholesterol
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Family Member
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Osteoporosis
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Family Member
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Stroke
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Family Member
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Bleeding Disorders
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Family Member
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Other
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Family Member
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