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Plan
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Laboratory Orders
• • •
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Laboratory Orders (Comments)
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Radiology Orders
• • •
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Radiology Orders (Comments)
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Alternative Treatment Recommendations
• • •
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Alternative Treatment Recommendations (Comments)
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Referrals
• • •
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Referrals (Comments)
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Past Medical Records
• • •
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Past Medical Records Comments
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Activity Instructions
• • •
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General Instruction (Comments)
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PT and Home Exercise
• • •
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PT and Home Exercise (Comments)
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Education
• • •
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Education (Comments)
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Physical Therapy Order
• • •
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Physical Therapy Order (Comments)
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Diet
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Diet Recommendations
• • •
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Diet (Comments)
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Urine Drug Test
• • •
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Urine Drug Test (Comments)
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Plan - select
• • •
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Plan
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Medication Adjustment
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Taper Opioid Medication
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Taper
• • •
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Comments
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Increase Opioid Medication
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Comments
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Maintain Opioid Medication
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Stop Soma
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Decrease Soma
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Medication Prescribed
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Narcotic
• • •
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Narcotic Number
• • •
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Narcotic Dose
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Narcotic Frequency
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Muscle Relaxer
• • •
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Muscle Relaxer Dose
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Muscle Relaxer Frequency
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Muscle Relaxer Number
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Other Meds - NSAIDS/neurontin
• • •
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Medication Comments
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BP Meds
• • •
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Additional
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Return to Clinic
• • •
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Additional Comments
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Pain Management Contract Signed
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Informed Consent (IC) Form Signed
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