Medicare Progress Notes - Pain Assessment
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
What is your PRIMARY REASON for today's visit?
*
Is this a New Accident, Injury or Condition?
*
Please Select
Yes
No
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What best describes the progress of your Primary Complaint:
*
I am feeling great!
There has been no change.
I am feeling better.
I have had a slight relapse.
I am feeling a little better.
I feel worse.
There has been a slight improvement.
Describe:
*
Please rate the level of pain for your Primary Complaint:
*
Please Select
1
2
3
4
5
6
7
8
9
10
0 = Symptom Free | 5 = Moderate Symptoms | 10 = Severe Symptoms
What is your SECONDARY REASON for today's visit?
*
What best describes the progress of your Secondary Complaint:
*
I am feeling great!
There has been no change.
I am feeling better.
I have had a slight relapse.
I am feeling a little better.
I feel worse.
There has been a slight improvement.
Describe:
*
Please rate the level of pain for your Secondary Complaint:
*
Please Select
1
2
3
4
5
6
7
8
9
10
0 = Symptom Free | 5 = Moderate Symptoms | 10 = Severe Symptoms
Signature
*
Back
Next
**Only Fill This Out If You Have a NEW INJURY**
Describe your NEW INJURY or CONDITION:
What caused this?
When did it occur?
-
Month
-
Day
Year
Date
Have you had this before? If yes, when?
Have you been treated for this before? If yes, when and by whom?
What is harder since the injury? (check all that apply)
Walking
Riding
Working
Bending
Standing
Sitting
Lifting
Coordination/Balance
Is this a result of:
Employment
Auto Accident
Personal Injury
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: