Medications, pain scores & pain map
Date
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Title
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Mr
Mrs
Ms
Miss
First Name
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Surname
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Date of Birth
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Email address:
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Medications & Dose
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Do you take any blood thinning medications?
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No
Yes, Aspirin (Astrix, Cartia, Solprin, Cardiprin, Asasantin, Aspro, Disprin, Spren etc.)
Yes, Clopidogrel (Plavix, Iscover, Plavicor, CoPlavix, DuoCover, Clovix, Piax, DuoPlidogrel)
Yes, Warfarin (Coumadin, Merevan)
Yes, new generation blood thinners (Pradexa, Xarelto, Brilinta, Tilodene, Effient, Eliquis)
Do you take tablets/injections for weight loss?
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Yes
No
Name your weight loss medications
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Tell us a bit about your pain
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Please rate your pain at its WORST in the past 24 hours
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0
1
2
3
4
5
6
7
8
9
10
(0 = No pain, 10 = Worst imaginable pain)
Please rate your pain at its LEAST in the past 24 hours
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0
1
2
3
4
5
6
7
8
9
10
(0 = No pain, 10 = Worst imaginable pain)
Please rate your pain level on an AVERAGE
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0
1
2
3
4
5
6
7
8
9
10
(0 = No pain, 10 = Worst imaginable pain)
In the past 24 hours, how much RELIEF have pain treatments or medications provided?
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0
1
2
3
4
5
6
7
8
9
10
(0 = Not much relief, 10 = A lot of relief)
Number that describes how much your pain has INTERFERED with your life in last 24 hours
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0 Does not interfere
1
2
3
4
5
6
7
8
9
10
(0 = No interference at all, 10 = I am unable to function/cope)
Mark your pain areas, where ever applicable
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Clear drawing
Mark your pain areas
Clear drawing
Foot and ankle pain
Clear drawing
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