Pain Assessment Consult

OVERALL_INSTRUCTIONS

Chief Complaint

Pain assessment consultation.

Template

Dear Dr. [Referring Physician Last Name], Thank you for referring [patient name] for a pain assessment. This [age][gender] was assessed today for [acute|subacute|chronic] [right|left|midline|bilateral|widespread|axial|axial and|L|R|appendicular|null] [neck|sneck|shoulder|arm|abdomen|flank|groin|low back|midline|buttock|thigh|knee|leg|foot|hip|null] pain. PAIN RELEVANT SURGICAL HISTORY: [Relevant pain interventions listed here, otherwise "none"] PAST MEDICAL PROBLEMS: [List medical problems here] RELEVANT PAIN HISTORY: Onset and Site: [Description of onset and site, duration, progression or suddenness, location, side] Quality: Pain is [intermittent|constant], lasting [seconds|minutes|hours|days|null]. Described as [dull|achy|sharp|shooting|electric|stabbing|hot|burning]. DN4 [positive|negative]. Radiation: [Describe specific side/anatomical distribution if present, otherwise "none"] Progression: Pain is [stable|worsening|improving] since onset. Provoking factors: [Describe] Palliating factors: [flexed posturing|extension|rest|exercise/stretching|laying flat|null] Severity: Mean daily value: [1–10]/10; Max daily value: [1–10]/10. Associated symptoms (red flags, autonomic, myelopathy): [none|bowel/bladder involvement|gait issues|null] BIOPSYCHOSOCIAL IMPACTS: Physical: [no|mild|moderate|severe]; walking [unassisted|with cane|with walker|uses wheelchair] ADL: [independent|partially dependent|dependent] Sleep: [no|mild|moderate|severe] impact; sleep [refreshing|unrefreshing|fragmented] Psychological: mood [good|seldom depressed|often depressed|anxious|frustrated]; kinesophobia [yes|no]; catastrophization [yes|no] Social: family supports [poor|few|good]; isolationism [yes|no] PREVIOUS PAIN THERAPIES: PT: [yes|previously tried|no]; benefit [n/a|worsened pain|mild|moderate|substantial] Massage Therapy: [yes|previously tried|no|null] Other: [OT|chiropractor|acupuncture|null] CBT/Psychological Resources: [yes|previously tried|no] TENS: [yes|previously tried|no] Previous Interventions: [none|null] Medication Trials: [none|list drugs|null] CURRENT PAIN MEDICATION: [List medications, dosages, tabs/day or "None"] ALLERGIES: Medications: [yes|no|unknown] Contrast Allergy: [yes|no|unknown] SOCIAL AND LIFESTYLE HISTORY: Housing: Lives in [house|apartment|assisted living] [alone|with spouse|with children] Occupation: [working as|retired|on disability since] Smoking: [never|ex-smoker: [packs/yrs]|current smoker: [packs/yrs]] Alcohol use: [no|yes|social|infrequent] Cannabis: [no|yes|CBD oil|THC oil|smokes dry cannabis] Illicit Drugs: [no|yes] PATIENT’S EXPECTATIONS: Pain: [30|40|50|60|70|80|90]% reduction Functional: [Insert if applicable] PHYSICAL EXAM: [If virtual: "A physical exam was not performed due to the virtual nature of this assessment."] If in-person: Gait: [Normal|Antalgic|With mobility aids] ROM: [Normal|Reduced in flexion/extension/lateral flexion/rotation/all directions], pain worse with [flexion|extension] Kemp’s Test: [+|negative|side specified] Palpation: [Tenderness noted|no tenderness] Dural Tension Tests: [positive|negative] Motor: [Muscle strength findings] Sensation: [Normal|abnormal findings] Reflexes: [Document findings for patellar, Achilles, Babinski, Clonus] Joints: [Document any joint issues] Skin: [document any skin issues] IMAGING STUDIES & INVESTIGATIONS: [Date and type of imaging with description] IMPRESSION: [List problems one per line] PLAN: 1. [Ongoing treatment, medication adjustments if any] 2. [New investigations ordered if applicable] 3. [Lifestyle or counseling recommendations] 4. [Referral if needed] FOLLOW-UP PLAN: [Timeframe for next Telehealth or in-person follow-up] [Indicate patient instructions for interim concerns (e.g., call clinic if symptoms worsen)] Thank you again for referring [name]. Please do not hesitate to contact me if you require any further information or clarification. Yours sincerely, [name]