Pain Management — Follow-up Template

Visit Information

Date: [Date]
Visit type: Follow-up / Medication refill / Post-procedure / Pre-procedure
Last visit: [Date]
Days since last visit: [X]

Interval History

Pain Status

Pain since last visit: Better / Same / Worse
Current pain levels (0-10):

• Primary location [Site]: [X]/10 — Previously: [X]/10
• Secondary location [Site]: [X]/10 — Previously: [X]/10

Average pain this month: [X]/10
Worst pain this month: [X]/10
Best pain this month: [X]/10
Pain pattern changes: None / [Description]
New pain locations: None / [Description]

Treatment Response

Medications:

Medication	Dose	Compliance	Efficacy (%)	Side Effects
[Drug]	[Dose]	Good/Fair/Poor	[0-100%]	[None/List]

Overall medication efficacy: [X]% relief
Duration of relief: [Hours per dose if PRN]
Breakthrough pain: None / [Frequency, triggers]

Procedures (if recent):

Last procedure: [Type, date]
Response: [X]% relief
Duration of relief: [X days/weeks/months]
Complications: None / [Description]

Other Treatments:

Physical therapy: Ongoing / Completed / Not engaged

• Response: [Improving / Same / Not helpful]

Home exercises: Doing regularly / Sometimes / Not doing
Other modalities: [Response]

Functional Status

Work:

Current status: Working / Not working / Disability
Changes since last visit: [None / Improved / Worsened]
Days missed due to pain (this month): [X]

Activities:

Activity	Previous	Current
Walking distance	[X]	[X]
Sitting tolerance	[X] min	[X] min
Standing tolerance	[X] min	[X] min
Sleep hours	[X]	[X]
Awakened by pain	[X] times	[X] times

Functional improvement: Yes / No / Stable
New limitations: None / [Description]

Validated Measures (if repeated):

Pain Disability Index: [X]/70 — Previous: [X]
Oswestry (if applicable): [X]% — Previous: [X]%
PHQ-9: [X]/27 — Previous: [X]
GAD-7: [X]/21 — Previous: [X]

Opioid Monitoring (if applicable)

Current Opioid Regimen:

Medication	Dose	Frequency	Daily MME
[Drug]	[X] mg	[X times/day]	[X]

Total daily MME: [X] mg
Change from last visit: None / Increased / Decreased

PDMP Review:

Date checked: [Today]
Last fill: [Date, drug, quantity, pharmacy]
Findings: Expected / [Concerns — early refills, multiple providers, etc.]

Urine Drug Screen:

Date: [X]
Results:

• Expected positives: [Prescribed meds] — [Present / Absent]
• Expected negatives: [Non-prescribed] — [Negative / Unexpected positive]
• Unexpected findings: None / [Description]

Interpretation: Consistent / [Concerns]

Compliance Assessment:

Pill count (if performed): [X] tablets present / [X] expected — [Consistent / Discrepancy]
Controlled substance agreement: Current / [Needs renewal]
Appointment adherence: Good / [Missed appointments]
Pharmacy: Single / [Multiple — concern]

Side Effects:

[ ] Constipation — Management: [X]
[ ] Sedation
[ ] Nausea
[ ] Cognitive effects
[ ] Falls/near-falls
[ ] None

Safety Concerns:

Naloxone prescribed: Yes / No / Declined
Sedating medications: [Benzodiazepines, muscle relaxants, sleep aids]
Sleep apnea: No / Yes — [On CPAP]
Fall risk: Low / Moderate / High

Red Flags Review

New neurological symptoms: No / Yes — [Description]
Bowel/bladder changes: No / Yes
Unexplained weight loss: No / Yes
Fever: No / Yes
New trauma: No / Yes

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
Weight: [X] — Change: [+/- X] from last visit
BMI: [X]

General

Appearance: [Well-appearing / In distress / Sedated]
Affect: [Appropriate / Flat / Anxious]
Gait: [Normal / Antalgic / Improved / Unchanged]

Focused Examination

[Targeted to pain condition]

Spine (if applicable):

ROM: [Improved / Same / Worse] — [Specific limitations]
Tenderness: [Location changes]
Neurological: Stable / [Changes]

Affected Area:

[Relevant findings]

Assessment

1) [Primary pain diagnosis] — [Status: Improved / Stable / Worsening]
Current: [X]/10 — Goal: [X]/10
Functional status: [Improved / Stable / Declined]
2) [Secondary diagnoses]
3) Treatment compliance: Good / Fair / Poor
4) Opioid therapy (if applicable):

• Efficacy: [Adequate / Inadequate]
• Safety: [No concerns / Concerns: X]
• PDMP/UDS: [Consistent / Concerns]

Plan

Medications

[ ] Continue current regimen
[ ] Adjust: [Medication, change]
[ ] Add: [Medication, dose]
[ ] Discontinue: [Medication, reason]
[ ] Taper: [Medication, schedule]
Opioid decision (if applicable):
[ ] Continue current dose — Rationale: [Stable pain, function, compliance]
[ ] Increase: [New dose] — Rationale: [X]
[ ] Decrease/taper: [Schedule] — Rationale: [X]
[ ] Rotate to: [New drug]
[ ] Discontinue: [Reason, taper plan]
Prescriptions:

Medication	Dose	Quantity	Days Supply
[Drug]	[Dose]	[#]	[X] days

Interventional

[ ] No procedures indicated
[ ] Schedule: [Procedure, date]
[ ] Repeat [Procedure]: [Rationale]
[ ] Refer for: [Procedure type]

Therapy/Behavioral

[ ] Continue current PT
[ ] New PT prescription
[ ] Psychology referral
[ ] Continue behavioral therapy

Monitoring

[ ] UDS at next visit
[ ] UDS before refill
[ ] Pill count next visit
[ ] PDMP check completed today
[ ] Controlled substance agreement renewal

Referrals

[ ] None needed
[ ] [Specialty] for [Reason]

Patient Education

• Treatment plan reviewed
• Medication safety (storage, disposal)
• Naloxone use (if prescribed)
• Activity/exercise importance
• When to call

Follow-up

Return: [X] weeks

• Purpose: [Routine f/u, pre-procedure, refill]
• Labs/UDS: [Before visit]
• Bring: [Medication bottles, imaging]

Next refill eligible: [Date]
Emergency contact: [Instructions]