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Location
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Location Comments
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Quality
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Quality Comments
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Average Pain level
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Severity Comments
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Duration
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Duration Comments
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Onset / Timing
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Onset Comments
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Context
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Context Comments
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Modifying Factors
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Modifying Factors Comments
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Associated Symptoms
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Associated Symptoms Comments
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Previous treatments
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Physical therapy
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Previous Injections:
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Anti-inflammatory medication
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Muscle relaxants
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Previous Surgery to the affected area:
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previous surgery
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Previous Pain Management Clinic:
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reason for leaving
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Name/ location of previous pain clinic:
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Current blood thinner usage:
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Recent Procedure:
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Previous procedures performed:
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Pain relief
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