ADVANCED INTERVENTIONAL PAIN CONSULTANTS
Follow Up Visit
Name _______________________________ Date of Birth __________ Age ____ Date ____________
PRIMARY CARE DOCTOR ___________________
CHIEF PAIN COMPLAINT
REFERRING PHYSICIAN _______________________
Back Neck Headaches Muscles Joints Shoulder Hip Knee
HISTORY OF PRESENT ILLNESS
How are you doing since your last visit? ___ Improved ___ No change ___ Worse Explain: ______________________________
Where is your pain located? Draw
How intense is your pain? Circle the lowest and highest
How do you best describe your pain?
___Dull ___Electrical ___Stabbing ___Burning
___Aching ___Throbbing ___Shock-like ___Sharp
What is the pattern of your pain?
___ Constant ___ Intermittent
___ Mornings ___ Afternoons ___ Nights
Does the pain radiate to other areas? ___Yes ___No
If yes, where? ____________________________
Any associated symptoms?
___ Numbness
___ Weakness ___ Muscle spasms ___ Tingling
Where are you headaches located? Draw
Fill this part only if you are being consulted for HEADACHES
How many headaches did you have last month? _____
How do they usually last? ________________
The intensity of the headaches is ___ better ___ worse ___ same
Have the medications we prescribed caused any of the following SIDE EFFECTS? (Circle all that apply)
Nausea
Vomiting
Itchiness
Constipation
Drowsiness
Sweating
Loss of libido
Weight gain
Swelling
Since your last visit, have you had a PAIN INJECTION? ___Yes ___No If yes, how much PAIN RELIEF did you obtain with the injection?
None
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Have you had PHYSICAL THERAPY in the last 6 months? ___ Yes ___ No
Date_________________ Did it help? ___ Yes ___ No
Has the TREATMENT you are receiving improved any of the following aspects of your life?
Activities of daily living
___ Yes
___ No
Relations with people
Ability to work
___ Yes
___ No
Sleeping/rest
Family life
___ Yes
___ No
Depression/anxiety
___ Yes
___ Yes
___ Yes
___ No
___ No
___ No
Overall, has the treatment you are receiving made a positive change in your condition? ___ Yes ___ No
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Are you ALLERGIC or sensitive to any medications? ___ No ___ Yes List ___________________________________________
List all OTHER MEDICATIONS you are currently taking. Include pain creams. Include dose and times per day taken
1)
2)
3)
4)
5)
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
6) _______________________________________________
7) _______________________________________________
8) _______________________________________________
9) _______________________________________________
10) _______________________________________________
Do you take any blood thinners? ___ No ___ Yes
OPIOID ATTESTATION I attest and certify that all of the following statements are true and factual:
___ I have used all medications prescribed to me exactly as prescribed.
___ I have reported all side effects to my physician.
___ I have not sold, given to someone else, or otherwise transferred my medications to anyone.
___ I have safeguarded my medications from theft.
___ I have not received, accepted, taken, or otherwise used any other opioid medications (narcotics) from any other source,
including from other physicians.
___ I have not received, accepted, taken, or otherwise used any illegal drugs.
___ I have not used alcohol while taking my opioid medications (narcotics).
Patient‘s Signature _________________________________
MEDICAL HISTORY Has your medical history changed since your last visit, including ER visits and hospitalizations? ___No ___Yes
Explain __________________________________________________________________________________________________
________________________________________________________________________________________________________
SURGICAL HISTORY Have you had surgery since your last visit? ___ No ___ Yes, explain _______________________________
_________________________________________________________________________________________________________
Do you smoke? ___ No ___ Yes, packs per day ____
Are you under psychiatric care or receiving counseling? ___ No ___ Yes
REVIEW OF SYSTEMS
Circle all that apply
1. General
2. ENT
Weight gain or loss, unexplained hair loss, fever or chills, low energy, too sleepy, too tired
Eye pain, vision problems (blurred vision, loss of vision), hearing loss, swollen glands in neck, sore
throat/pain when swallowing, dental problems
Chest pain (sharp, crushing, or heaviness), heart racing (palpitations), fainting spells, shortness of breath,
swelling of legs (edema)
Shortness of breath, cough/coughing up blood
Increased appetite, decreased appetite, stomach pain, nausea/vomiting, diarrhea, constipation
Pain when passing water (urination), blood in urine, urinating more than usual (day and/or night), bladder
Infection, pain during sex, changes in sex drive (libido)
Limited motion of arms or leg, joint pain, swelling/redness, numbness, tingling, or weakness in arms or legs
Arm/leg weakness, new headaches, problems with memory or speech, tremors
Sadness, stress, anxious, seeing or hearing things, suicidal thoughts, feeling down, insomnia
Weight gain/loss, thirsty all the time, cannot stand temperature changes (heat/cold)
Swollen glands (armpits or groin)
Rash (palm of hands, sole of feet), changes in skin, sores or rash on skin
Hives/skin rashes, allergic reaction to foods
3. Cardiovascular
4. Respiratory
5. Gastrointestinal
6. Genitourinary
7. Musculoskeletal
8. Neurological
9. Psychiatric
10. Endocrine
11. Lymph
12. Skin
13. Allergies
____ No new problems
SLEEP APNEA SURVEY
___ Excessive loud snoring ___ Gasping or choking for breath while sleeping ___ Tired after sleeping
___ Falling asleep and daytime tiredness ___ Witnessed respiratory pauses ___ Night time difficulties ___ Have high blood pressure
I attest that all of the information I have provided is accurate and factual, and I can provide supporting information.
Patient‘s Signature __________________________________
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PHYSICAL EXAM
VITAL SIGNS
HR ______ BP ____________ RR ______ Weight _________ Height _________ BMI _______
GENERAL
___ Alert ___ Somnolent ___ Calm
___ Distressed ___ Pain behavior ___Clear speech
___ Pupils are round and equal, patient used adequate respiratory efforts and pulses are present
MUSCULOSKELETAL
___ Cane ___ Walker ___ Wheelchair ___ Brace ___ Sling
Inspection: Area _____________________ ___ Asymmetry ___Scars ___Atrophy ___ Scoliosis deformity ___ Kyphosis deformity
___ Midline posterior lumbar/cervical scar(s) ___ Anterior abdominal scar ___ Anterior neck scar
Palpation: Tender or trigger point areas and/or muscle spasm
___ Masseters
___ Supraspinatus ___ Gluteus max
___ Splenius capiti ___ Infraspinatus ___ Gluteus med
___ Semispinalis ___ Rhomboid
___ Piriformis
___ Trapezius
___ Latissimus
___ > 11/18 tender
___ Deltoid
___ Paraspinalis
points (FM)
ROM:
NEURO
Facet joints pain/positive facet joint loading test
___ C2-3 ___ T1-2 ___ T7-8
___ L1-2
___ C3-4 ___ T2-3 ___ T8-9
___ L2-3
___ C4-5 ___ T3-4 ___ T9-10 ___ L3-4
___ C5-6 ___ T4-5 ___ T10-11 ___ L4-5
___ C6-7 ___ T5-6 ___ T11-12 ___ L5-S1
___ C7-T1 ___ T6-7 ___ T12-L1
Painful areas
___ Supraorbital
___ Temporal
___ Occipital
___ AC Joint
___ Greater trochanter
___ Infrapatellar ___ IT Band
___ Suprapatellar ___ SIJ Pain
___Lumbar
___Cervical
___Thoracic
___Hip
___Shoulder
___Knee
___Ankle
___Elbow
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Extension
___ Extension
___ Extension
___ Extension
___ Extension
___ Extension
___ Extension
___ Extension
___ Distraction
___ Thigh Thrust
___ Compression
___ Gaenslen
___ Faber
___ SIJ 3/5 Positive
___ Rotation ___ Lateral Bend
___ Rotation ___ Lateral Bend
___ Rotation ___ Lateral Bend
___ Patrick-Faber (Hip/SIJ) ___ Resisted Abd Release (GT bursa)
___ Abd ___ Add ___ Internal/External rotation ___ Drop Arm Test (RCT)
___ACL-PCL Drawer ___ MCL Test ___LCL Test ___ McMurray’s (meniscus)
___ Inversion ___Eversion
___ AAO x 4
___ CN 3-12 intact
___ Normal Gait
___ Cerebellar function test normal (nose-finger-nose)
___ Normal motor function (5/5) ___ Normal deep tendon reflexes (2/4) ___Normal sensory function
___Allodynia ___Hyperalgesia ___Edema ___Erythema ___Cyanosis ___Cold/warm ___Hair pattern ___Skin
___ Abnormal motor function Right
Arm flexion/deltoid abd (C5) ___/5
Writs extension (C6)
___/5
Arm extension (C7)
___/5
Hand grip (C8)
___/5
Hip flexion (L2, 3)
___/5
Knee extension (L4)
___/5
Ankle dorsiflexion (L5)
___/5
Ankle plantar flexion (S1)
___/5
Left
___/5
___/5
___/5
___/5
___/5
___/5
___/5
___/5
___ Abnormal deep tendon reflexes
Biceps (C5)
___/4
Brachioradialis (C6)
___/4
Triceps (C7)
___/4
Patellar (L4, 5)
___/4
Achilles (S1)
___/4
___/4
___/4
___/4
___/4
___/4
___ Decrease light touch/pin prick sensation
___ Cervical axial loading test (disc)
___ Lumbar axial loading test (disc)
___ SLR Right Left
___Spurling Right Left
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NEW MEDICAL RECORDS: ___Reviewed ___Not Available
MRI: Date ________ ___ Reviewed
XRAY: Date _________ ___Reviewed
CT SCAN: Date ________ ___Reviewed
EMG: Date _________ ___ Reviewed
URINE DRUG TEST Date: ______________ ___ Passed ___ Failed
Inclinometry and muscle strength test: ___ Done today ___ Reviewed
SOAAP-R Score:
PMQ-R Score:
DEPRESSION Score:
DPS Report:
SLEEP APNEA Survey:
____
____
____
____ Reviewed
____ Done
ASESSEMENT:
___ Stable medication regimen
___ Adequate analgesia
___ Adequate level of activity
___ No abuse, misuse, aberrant, addiction behavior
___ No significant/significant side effects
___ Rotate to a different opoid _______________________________
___ Increase/decrease total dose
___ Start weaning opioid off
___ Low/average/high risk
___ Violation of medication contract
LUMBAR
___ Lumbalgia
___ Facet arthralgia/arthritis
___ Spondylosis
___ DDD
___ HNP
___ Radiculopathy
___ Stenosis
___ Pseudoclaudication
___ Listhesis
___ Scoliosis
___ FBSS
___ Compression fracture
___ Foraminal stenosis
CERVICAL
___ Cervicalgia
___ Facet arthralgia/arthritis
___ Spondylosis
___ DDD
___ HNP
___ Radiculopathy
___ Stenosis
___ Listhesis
___ Kyphosis
___ FBSS
___ Foraminal stenosis
THORACIC
___ Thoracalgia
___ Facet arthralgia/arthritis
___ Spondylosis
___ DDD
___ HNP
___ Radiculopathy
___ Stenosis
___ Scoliosis
___ Kyphosis
___ Compression fracture
___ PTPS
___ PMPS
___ Costochonditits
HEAD
___ Cervicogenic headaches
___ CDHA
___ Migraine
___ Occipital neuralgia
___ Supraobital neurlagia
___ Trigeminal neuralgia
___ Central pain
___ Seizures
___ CVA/TIA
___ TMJ syndrome
___ Atypical facial pain
PELVIS
___ Hip pain
___ Hip arthritis
___ Trochanteric bursitis
___ Piriformis syndrome
___ SIJ pain
___ Sacroilitis
___ SIJ dysfunction
___ Coccygodynia
___ Pelvic pain syndrome
___ Interstitial cystitis
___ Vulvodynia
___ Genital pain
___ Endometriosis
JOINTS
___ Shoulder pain
___ Shoulder arthritis
___ RC impingement
___ Rotator cuff strain
___ Rotator cuff tear
___ AC arthritis
___ SA bursitis
___ Knee pain
___ Knee arthritis
___ MCL LLC ACL/PCL
___ Meniscus tear (M/L)
___ Elbow pain/arthritis
___ Foot/ankle pain
___ Synovial bursa tendon
___ Hand/wrist arthritis
NERVES/MUSCLES
___ Fibromyalgia
___ Myofascial pain syd
___ Muscle spasms
___ CRPS arm
___ CRPS leg
___ Neuralgia/neuritis
___ Polyneuropathy idiopathic
___ DPN ___ PHN
___ CTS
___ Phantom pain syd
___ Neuroma
___ Paraplegia
___ Meralgia
___ Post-polio syd
___ Multiple sclerosis
CONNECTIVE
___ Osteoarthritis
___ Osteoposis
___ Rheumatoid arthritis
___ Psoriatic arthritis
___ Ankylosing Spondylitis
___ Sjogren’s
___ SLE
___ Enhlers Danlo’s syndrome
___ Raynaud’s
___ Enthesopathy
___ Plantar fasciitis
___ IT band pain/fasciitis
___ Thoraco-scapular syndrome
VARIOUS
___ Abdominal pain
___ Chronic pancreatitis
___ PAD
___ Ischemic pain
___ Adhesions
___ Post-surgical pain
___ Tumor pain
___ Kidney pain
___ Obstructive sleep apnea
PSYCH
___ Depression
___ Anxiety
___ Bipolar
___ PTSD
___ Alcohol dependence
___ Drug dependence
___ Drug withdrawal
___ Chronic pain syndrome
___ Insomnia
___ Drug abuse/misuse
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TREATMENT PLAN:
The goal of treatment is/are ___ pain relief, ___ optimize medication use, ___ improve function.
1. ___Pharmacologic therapy: ___ Medication’s risks (side effects) and benefits were discussed with patient.
OPIOIDS Post date _________________ Refills ___
Tylenol 3 4 1 ________ # ____ PRN
Tramadol 50 mg 1 ________ # ____ PRN
Oxycodone 5 10 15 30 mg 1 _______ # ____ PRN
Opana 5 10 mg 1 ________ # ____ PRN
Hydromorphone 2 4 8 mg 1 ________ # ____ PRN
Tapentadol 50 75 100 mg 1 q6 hrs # ____ PRN
Morphine IR 15 30 mg 1 ________ # ____ PRN
Hydrocodone 5 7.5 10 mg 1 ________ # ____ PRN
APAP 325
Butrans 5 10 15 20 mcg/hr 1 q 7 days # ____
Ultram ER 100 200 mg 1 qd # ____
MUSCLE RELAXANTS PRN MUSCLE SPASM Refills ____
Tizanidine 2 4 6 mg 1 qHS bid tid
# ____
Flexeril 5 10 mg 1 qHS bid tid
# ____
Soma 250 350 mg 1
qHS bid tid qid # ____
Baclofen 10 20 mg ½ 1 tid
# ____
Methocarbamol 500 750 mg 1 tid qid
# ____
ANTI-INFLAMMATORIES Refills ____
Etodolac 400 mg 1 q12 hrs # ____
Ibuprofen 800 mg 1 q8 hrs # ____
Meloxicam 7.5 15 mg 1 qd bid # ____
Oxycontin 10 15 20 30 40 60 mg 1 q8 q12 hrs # ____
Opana ER 5 7.5 10 15 20 30 40 mg 1 q12 hrs #
Exalgo 8 12 16 32 mg 1 ____ qd # ____
Morphine ER 15 30 60 mg 1 q8 q12hrs # ____
Nucynta ER 100 150 200 250 mg 1 q12 hrs # ____
Zohydro 10 15 20 30 40 50 mg 1 q12 hrs # ____
Methadone 5 10 mg 1 q12 q8 q6 hrs # ____
Fentanyl 12 25 50 75 100 mcg/hr 1 q72 q48 hrs # ____
Kadian 20 30 50 60 80 100 200 mg 1 q12 hrs # ____
Avinza 30 45 60 75 90 120 mg 1 qd # ____
ANTI-CONVULSANTS Refills ____
Lyrica 25 50 75 100 mg 1 qHS bid tid # ____
Neurontin 100 300 400 600 800 mg 1 qHS bid tid qid # ___
ANTI-DEPRESSANTS Refills ____
Cymbalta 20 30 60 mg 1 qd bid # ____ Refills ____
_________________ mg 1 qd bid # ____ Refills ____
ANXIOLYTICS PRN ANXIETY Refills ____
Alprazolam 0.25 0.5 1 2 mg 1 qd bid tid # ____
Clonazepam 0.5 1 2 mg ½ 1 bid # ____
TOPICAL Compound Cream Anti-inflammatory Neuropathic Combination apply 1-2 gms to affected areas 120 240 gm 5 refills
Lidodem 5 % Patches apply 1 2 to affected areas q12 hrs on/12 hrs off # ____
2. ___ Interventional pain procedures:
1) _____________________________________
2) _____________________________________
3) _____________________________________
4) ______________________________________
7. ___ Psychological testing
SOAAP-R
PMQ-R
3. ___ Physical therapy:
___ Land ___ Aquatic ___ Home Health
___ times per week for ___ weeks
9. ___ Psychological Evaluation:
___ Spinal cord stimulator trial
___ Suitability for chronic opioid use
___ Counseling ___ Biofeedback
4. ___ Imaging:
___ MRI
___ XRAY
___ CT SCAN
___ Myelogram
___ Bone scan
___ Lumbar
___ Cervical
___ Thoracic
___ Hip
___ Pelvis
___ Knee
___ Shoulder
6. ___ Urine drug testing: ___Today ___Next visit
___ As per PMQ protocol ___ Every visit
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BBHI2
8. ___ Inclinometry and Muscle Strength Testing
___ Today
every ___ months
10.___ Referral for consultation
Dr. _________________________________
Reason ______________________________
11. ___ Sleep Study. Diagnosis: OSA
5. ___ EMG/NCS: Dr. Al Baeer Dr. Nammour Dr. Yasser
___ Upper ___ Lower extremities
Level of service FOLLOW UP VISIT
Depression
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12. ___ Run DPS report
13. ___ Follow up ___ month(s) ___ week(s)
___ Review UDT
___ Med refill
___ Review imaging
___ Post procedure(s)
___ Obtain patient’s medical records
_____________________________ Jaime Robledo, M.D.
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