Providers: Please complete this form to provide information about your patient to the panel. Please circle all
that apply or write in answers when appropriate.
  1. What is your primary question for the group? What do you need help with?
  1. H&P:
  • Pain Location(s):
  • Pain Description: dull/ache, cramping, hot/burning, shooting, sharp/stabbing, squeezing, throbbing, tingling/pins & needles, other ______
  • Timing: morning, daytime, evening, middle of the night, awakens from sleep, other ______
  • Exacerbating Factors (what makes the pain worse): bending, driving, cough/sneeze, lifting, looking up/down, rising from seated, standing, stairs, walking, weather, other ______
  • Pain Type(s): Neuropathic, Nociceptive, Visceral, Somatic, compressive, ischemic, distention/compression, central, inflammatory, other ______
  • Alleviating Factors (what makes the pain better):
  • Diagnostics: MRI, CT, Xray, EMG/NCV, Labs, other ______
  • Known, stated, or presumed etiology and other associated diagnoses:( RA, OA, fibromyalgia, Sickle Cell, etc)
  • Opioid Related Adverse Drug Event Risks (ORADER):
Does the patient have any of the following risk factors for severe opioid adverse events? (Y/N)
Geriatric (age 65) / YES/NO
SignificantObesity (BMI 35) / YES/NO
Significant PsychiatricDisorder
(e.g. depression, anxiety, panic, bipolar, schizophrenia) / YES/NO
SubstanceAbuse
(e.g. alcohol, illicit drug use) / YES/NO
Central Nervous System/CognitiveDisorder
(e.g. stroke, dysphagia, neuromuscular disease, dementia) / YES/NO
Respiratory Disorder
(e.g. sleep apnea, COPD/emphysema, asthma, cystic fibrosis,
obesity hypoventilation syndrome) / YES/NO
Sedating Medications
(e.g. benzodiazepines, hypnotics, sedating antihistamines, muscle relaxants, etc) / YES/NO
  • Treatments tried: acetaminophen, acupuncture, antidepressants, antiepileptic, brace, chiropractic, hot/cold, injection, massage, manipulation, meditation, muscle relaxants, nerve block, NSAIDs, opioids, psychological support, PT/OT, radio-ablation surgery, tens, other: ______
  • Specialists: chiropractor, integrative medicine, neurosurgery, neurology, Osteopath, pain specialist, Physical therapist, PM&R, psychiatry/psychology, rheumatology, other: ______
  • Opioids:
Opioid (brand names) / Sig / Disp / Refill frequency
Codeine
(Fioracet w/codeine,Tylenol #3, Guaiatussin AC, Robitussin AC)
Fentanyl
(Duragesic)
Hydrocodone (Norco/Vicodin/Lortab)
Hydromorphone
(Dilaudid)
Methadone
Morphine
(MS Contin, Roxanol, Kadian)
Oxycodone
(Oxycontin, Percocet)
Tramadol
(Ultram, Ultracet)
Other:
  • Additional Current Relevant Medications (Tylenol, NSAIDs, SSRI/SNRI/TCA, antiepileptics, muscle relaxants, etc)
  • Significant/relevant exam findings:

Substance Use:
Prior Hx or current? / Last use? / treatment? / Problems? (jail, dui, job loss etc)
Cigarettes/tobacco
Alcohol
Marijuana
Cocaine
Amphetamines
Other
Psychosocial History
Relevant Family History:
Psychiatric History:
Occupation:
Recreational Activities:
Any relevant relationships:
Goals
Patient goals:
Providers goals:

DATA: (if already done)

4 A’s:

ORT:

PHQ2/9:

GAD 2/7:

Maximum prescribed daily morphine equivalent dose:

PDMP date:

Any evidence of aberrant behaviors? :

UDS date:

Any unanticipated results? :

DIRE score: