eo PROGRESS NOTE. Please shade area where your pain is located on the PAIN ASSESSMENT AND DOCUMENTATION TOOL (PADT) diagram below. Patient Name: Pain Level (0-10): 012345678910 Chief Complaint: Pharmacy Name Recent MRICT/XRay Yes / No_ iffyes give report and CD/Films to receptionist Auto/Work Comp Related Yes/ No ‘Address/Phone/Insurance Changes Yes / No Current Pain Medication Strength Frequency Recent Pain Procedures/Dates: Patient’s Signature: Analgesia ‘Activities of Daily Living ‘Adverse Effects zero indiats “no pin” and ten nd Please indicate whether you are functioning with your | [Are you experiencing anys it can be," on a scale of Oto 10, what is y current pain relievers is Better, the Same, ‘fom current pain reliever? forthe following questions? or Worse since last visiVassessment. (Cirele answer below) Nausea None Mild Severe . Vomiting None Mild Severe NoPaind 123456789 10 painasbadasit || 1. Physical functioning Beter Same Worse | | Constipation None Mild Moderate Severe canbe 2. Familyreationships Beer Same Worse | | jiching None Mild Moderate Severe 2. What was you pin level tits worst during the past week? 3. Social relationships Better. © Same Worse moat loudness None Mild. Moderate Severe NoPaind 123456789 10 painasbadasit || 4 Mood Bewer Same Worse canbe Sweating None Mild Moderate Severe 5. Sleep pattems Bate Same Worse 3. What percentage of your pain ha ben relieved Fatigue None Mild Moderate Severe medications diring the pas week? 6. Overall functioning eter Same Worse . percentage between 0% and Drowsiness None Mili Moderate Severe a Other___ None Mild Moderate Severe a axe now obtining from enough to make Oter___ None Mild Marte Severe area ‘Yes No