TRICARE



Tripler Army Medical CenterInterdisciplinary Pain Management ClinicFollow Up Pain Assessment ToolName:Date of Birth:Primary/Mobile Phone:MOS/Occupation:Present Pain Level?012345678910In the past 24 hours how much has pain interfered with your ACTIVITY?012345678910In the past 24 hours how much has pain interfered with your SLEEP?012345678910In the past 24 hours how much has pain affected your MOOD?012345678910In the past 24 hours how much has pain affected your STRESS?012345678910In the past month what is your AVERAGE pain level?012345678910In the past month what was your HIGHEST pain level?012345678910In the past month what was your LOWEST pain level?012345678910Location of your pain:Do you use any type of tobacco or nicotine?□ Yes□NoDo you drink alcohol?□ Yes□NoHow many times in the past year have you used an illegal drug or used a prescription medication for non-medical purposes?Do you have any allergies to foods or medications?□ Yes□NoAre you having any medication side effects?□ Yes□NoIs this visit related to deployment?□ Yes□NoDo you have any barriers to learning?□ Yes□NoAre you currently on permanent profile?□ Yes□NoAre you currently on temporary profile?□ Yes□NoAre you currently in MEB or WTU or on disability/con leave/alternate duty?□ Yes□NoHas our clinic helped you to better manage your pain?□ Yes□NoAre you taking blood thinners? (Coumadin/Warfarin, Ticlid/Ticiopidine, Ginko, Aspirin, Heparin, Lovenox/Enoxaparin, Apixaban/Eliquis, Betrixaba/Bevyxxa)□ Yes□NoPlease list current career goal(s):Please list current exercise regimen:Please list additional sports/recreational/fun activities:Are you getting at least 6 hours of good sleep? (restful and less than 2 awakenings)□ Yes□NoAre you on the Anti-Inflammatory diet or other specific diet?□ Yes□NoHow willing are you to make major changes in your diet? (0 = not at all)012345678910How willing are you to make major changes in your exercise regimen?012345678910How willing are you to make major changes in your life? 012345678910Review of Systems (Please circle all that apply):Fever/ChillsCoughShortness of BreathNew loss of Taste or SmellUnusual/Severe HeadachesGeneralized Body Aches/PainNausea/Vomiting/DiarrheaNumbness of Arms or HandsNumbness of Legs or FeetUnusual/Severe FatigueSexual ProblemsUnexplained Weight LossLoss of Bladder ControlLoss of Bowel ControlDepressed MoodLoss of Sensation /Tingling to the Genital RegionLoss of Interest/Pleasure in Doing ThingsThoughts of Self-harm/SuicidePlease indicate all treatments you have tried to help your pain:TREATMENTHave you tried it?Do you currently use it?Does it help?TENS Unit□ Yes □ Yes □ YesRolling/Ball Rolling/Self Massage□ Yes □ Yes □ YesCupping/Gua Sha□ Yes □ Yes□ YesTraction or Inversion Table use□ Yes □ Yes □ YesStretching□ Yes□ Yes □ YesPT directed home exercises□ Yes □ Yes □ YesBiofeedback/Self Regulation□ Yes □ Yes □ YesPlease list any procedures, surgeries, or new medical problems diagnosed (since your last visit):Doctor/Clinic/HospitalProcedure/Reason/DiagnosisPlease list all medications, herbs, and supplements that you are currently taking (not just pain medication):Name of MedicationDoes it Help?Name of MedicationDoes it Help?□ Yes □No□ Yes □No□ Yes □No□ Yes □No□ Yes □No□ Yes □No□ Yes □No□ Yes □NoHEIGHT:WEIGHT:PULSE:BP:RESPRIATIONS: ................
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