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PAIN MANAGEMENT INITIAL EVALUATION

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Was it the result of an injury or accident?*
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Timing of Pain:


Timing of Pain:

How often do you have your pain? (please check one)

Pain Quality:


Pain Quality:

How would you describe the pain? (check as many adjectives as are applicable)
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Rate Your Pain Intensity:


Rate Your Pain Intensity:

0 = No pain; 10 = worst pain imaginable
Choose the number below that best describes the WORST your pain level gets:
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Choose the one number that best describes the BEST your pain level gets:
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RELIEVING AND AGGRAVATING FACTORS


RELIEVING AND AGGRAVATING FACTORS

Indicate whether the following activities improve or worsen pain
Sitting
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Standing
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Walking
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Driving
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Bending
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Turning
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Twisting
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Stretching
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Looking up
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Looking down
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Lying on back
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Reclining
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Laying on side
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Support with pillows
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Ice application
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Heat application
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Changing position
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Distraction
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Relaxation/meditation
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Doing something pleasant or fun
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Resting
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PREVIOUS PAIN TREATMENTS


PREVIOUS PAIN TREATMENTS

Please add descriptions for any of the following treatments you have tried.
Chiropractic
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Physical Therapy
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Biofeedback
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Acupuncture
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Dry Needling
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Psychotherapy
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Massage Therapy
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Ketamine Infusion
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Joint Injections
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Spine Injections
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Radio Frequency Ablation
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Trigger Point
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Surgery: (list)
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Medications


Medications

Check any medications you have EVER been on or are CURRENTLY taking:
NSAIDs
Muscle Relaxant
Adjuncts
Short-Acting Opiates
Long-Acting Opiates
Migraine
Have you been given/prescribed a form of Narcan to use in case of emergency?
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SSRI/NSRI Treatments
Mood Stabilizers
Atypical
Benzo
Sleep Aids

Pain Catastrophizing Scale


Pain Catastrophizing Scale

Pain Catastrophizing Scale (Copyright 1995, 2001, 2004, 2006, 2009 Michael JL Sullivan, PhD) Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.
We are interested in the types of thoughts and feeling that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.
Key for scoring: Not at all = 0, To a slight degree = 1, To a moderate degree = 2, To a great degree = 3, All the time = 4
I worry all the time about whether the pain will end.
Please select an option.
I feel I can't go on.
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It's terrible and I think it's never going to get any better.
Please select an option.
It’s awful and I feel that it overwhelms me.
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I feel I can’t stand it anymore.
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I become afraid that the pain will get worse
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I keep thinking of other painful events
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I anxiously want the pain to go away
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I can’t seem to keep it out of my mind
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I keep thinking about how much it hurts
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I keep thinking about how badly I want the pain to stop
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There’s nothing I can do to reduce the intensity of the pain
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I wonder whether something serious may happen
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Patient Health Questionnaire (PHQ-9)


Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
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Feeling down, depressed, or hopeless
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Trouble falling or staying asleep, or sleeping too much
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Feeling tired or having little energy
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Poor appetite or overeating
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Feeling bad about yourself or that you are a failure, or have let yourself or your family down
Please select an option.
Trouble concentrating on things, such as reading the newspaper or watching television
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Moving or speaking so slowly that other people could have noticed; or the opposite, being so fidgety or restless that you have been moving around a lot more than usual
Please select an option.
Thoughts that you would be better off dead or of hurting yourself in some way
Please select an option.
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In the past 2 weeks, to what degree did your pain alone interfere with your ability to enjoy lifee
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In the past 2 weeks, to what degree did your pain interfere with your general activities (defined as your ability to do those things that needed to be done like housekeeping, laundry, shopping, meals, bathing, dressing, toileting)?
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Questionnaire (FAQ5)


Questionnaire (FAQ5)

This tool has not been validated for research: however, work group consensus was to include it as an example due to the lack of other validated and easy-to-use functional assessment tools for chronic pain.
Choose the number (1-4) in each of the groups that best summarizes your ability. Add the numbers and multiply by 5 for total score out of 100.
Self-care ability assessment
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Family and social ability
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Movement ability assessment
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Lifting ability assessment
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Work ability assessment
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Other Treatments


Other Treatments