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Why are you taking pain medication (where is your pain)?
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What is your average daily pain score (0=no pain, 10=absolute worst pain)?
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What is your pain score when you feel your best?
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What is your pain score when you feel your worst?
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What pain medication are you currently taking? (list name, strength, frequency and max # of tablets per day)
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Are you taking any other meds (rx or over-the-counter) or using other products (CBD) for pain? (list name, strength, frequency)
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Are you having any side effects from your pain medication?
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What were you taking for pain prior to surgery? (list name, strength, frequency and max # of tablets per day)
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How much sleep are you getting each night?
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How far are you able to walk?
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How many times per day?
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Compared to prior to surgery, how would you rate your health in general now?
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Describe your physical abilities (check all that apply):
• • •
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Over the past 1-2 weeks, how much of the time has your physical health interfered with your regular daily or social activities?
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Are you taking any benzodiazepines? If yes, please explain why and list name, strength and frequency).
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Do you use or have history of marijuana use or illicit drug use (cocaine, heroin, methamphetamines)?
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