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Plan
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Procedures
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Lumbar Procedures
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Additional Procedure or ODG (Free Text)
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Cervical Procedures
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Additional Procedure or ODG (Free Text)
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Procedures #3
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Additional Procedure or ODG (Free Text)
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Joints/Occipital/Other Procedures
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Additional Procedure or ODG (Free Text)
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Tigger Point Injections (List locations)
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Reason for sedation/anesthesia?
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Local Anesthesia for Procedure
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Conservative Care/Declined/Hesistant (list procedures)
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Procedures if Pain Worsens (list procedures)
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Conservative Treatment
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Therapy
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Conservative care:
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New Multiple Select
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Imaging
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MRI Imaging #1
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CT Imaging #1
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MRI Imaging #2
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CT Imaging #2
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MRI Imaging #3
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CT Imaging #3
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Other Imaging Tests (List- Will populate)
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CT over MRI reason
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Image Reviewed
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Incidental Findings
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List Findings (Will populate)
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List Physician for workup (Will populate)
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Referrals
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Specialist Referred
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Medications
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Avoided Med #1
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Avoided Med #2
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New Meds
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Continue Meds
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Continue meds from ER (List - Med Only)
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Cont meds from other physician (List Med Only)
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Meloxicam 7.5mg BID
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Meloxicam 7.5mg BID
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Meloxicam 15mg QD
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Meloxicam 15mg QD
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Celecoxib 200mg BID PRN
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Celecoxib 200mg BID
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Cyclobenzaprine BID/TID
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Cyclobenzaprine BID/TID
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Cyclobenzaprine qHS
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Cyclobenzaprine qHS
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Tizanidine BID PRN
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Tizanidine 4mg TID
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Diclofenac 1% TID
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Diclofenac 1% TID
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Diclofenac 1.5% TID
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Diclofenac 1.5% TID
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Diclofenac 3%
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Diclofenac 3%
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Lidocaine Patches qHS
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Lidocaine Patches qHS
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Viva Patch qHS
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Viva Patch qHS
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Ondansetron
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Alprazolam (Procedures/Imaging)
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Omeprazole
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Tramadol ER 100mg qD
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Tramadol 50mg BID
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Other new med prescribed (List - Will Populate)
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Stop Meds (List - Will populate)
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Clinic Screening: Drug Screen will be performed today as part of the pain clinic protocol.
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DME
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DME Prescribed
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Follow Up
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Work Status
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Off Work
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Full Work Duty
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Light Work Duty
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Light Work Selections
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Off work for PT/Clinic visits.
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Disability Paperwork
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Telehealth Statement
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