PREOPERATIVE QUESTIONNAIRE - St. Mary Medical Center ...

PREOPERATIVE QUESTIONNAIRE ADVANCED HEALTH CARE DIRECTIVE PAIN SCREENING Do you have an Advanced Directive (Living Will)? Yes No 1. Do you have a chronic problem with pain? Yes No Are you an organ donor? Yes No If yes, where is your pain located? Do you have a medical power of attorney? Yes No 2. Rate the severity of your pain: (O= no pain, 10 ... ................
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