Pain Management Pharmacy Assessment
Today's Date
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Personal Information
Name
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First Name
Last Name
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Phone Number
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Area Code
Phone Number
Date of Birth
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Pharmacy Data
Did you have to see a clinician for your health in the past 28 days for other reasons other than pain management? If yes, please explain below. If the answer is no simply type no in the box below.
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Are you taking any herbal supplements, vitamins, and/or Over-the-counter medications other than what you are prescribed? If yes , please explain below. If the answer is no simply type no in the box below.
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Are you currently taking any medications not dispensed at our pharmacy? If yes, please list them below and indicate the purpose and reason. If the answer is no simply type no in the box below.
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Are you pregnant?
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Yes
No
Did you have to see a clinician for your health in the past 28 days for other reasons other than pain management?
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Yes
No
Do you feel that your pain management prescriber is managing your pain levels well?
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Yes
No
On a scale from 1-10, what is your average pain level without pain medications?
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No Pain
Worst Pain Ever!
1 is No Pain, 10 is Worst Pain Ever!
On a scale from 1-10, what is your pain level if you take your pain medications?
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10
No Pain
Worst Pain Ever!
1 is No Pain, 10 is Worst Pain Ever!
Are your suffering from any of these side effects from taking pain medications?
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None
Yes
I'm not sure
Not applicable
Itching
Constipation
Nausea and/or Vomiting
Irregular Heart Beats
Involuntary Muscle Movement/Jerking
Swelling on the feet, ankles, and legs
Dry Mouth
Decreased Estrogen levels: tender breast, dry skin, difficulty concentrating, vaginal dryness, hot flashes, irregular menstrual cycles.
Decreased Testosterone levels: erectile dysfunction, low sex drive, depressed mood, difficulty concentrating, fatigue, moodiness/irritability, loss of muscular strength.
Are you urinating less frequently?
Do you have any concerns or questions for our pharmacy staff before your next refill?
Patient Signature
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Date Signed
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