Follow Up

Date: 09/27/2023

DOI: 05/01/2023

General Info:

Name: Raymond "Mr. Inbetween" Shoesmith Phone: 3806996699

DOB: 08/12/1972 Mobile phone: 3806996669

SSN: 123987456 Address: вулиця Бельведерська 32, Bldg 96, Івано-

Франківська міськрада, Івано-Франківська область
Law Office: South Park insurance 76000
Attorney: Primary Insurance Holder:

Patient Comfort Assessment Guid:

Where is your primary pain location? Head

Check two words that best describe your pain: Dull Nagging

How has your sleep been? Disturbed Awaken with pain? Yes

What makes your pain better? Drugs

Do you have any new areas of pain? No Where?

How long have you had the new pain? 3 days

Choose a number that describes your pain on average in the week with medication use: 4

Rate your pain by circling the number that best describes your pain at its worst: 6

Rate your pain relief with the treatment or medicine we provided you: 8

What side effects or symptoms are you having? Check what best describes your experience during the past
week? Check all that apply
Cough Chest pain Depression Stomach pain