Follow up visit documentation - pain management clinic located in Palm Harbor, Florida

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Follow Up Visit Documentation Form

Fields marked with '*' are required.

The downloadable Follow Up Visit Documentation Form allows you to print and fill out the form necessary for the follow up visit documentation at your convenience at home. Just bring the filled out form with you to your appointment with Dr. Columbus.

click image to download
or
right-click and select "Save Target As..." (file size is ~1.2 MB)

The Form is an Adobe Acrobat (.pdf) file. If you don't already have the Adobe Acrobat Reader installed on your PC, you can download the current version free of charge at: http://www.adobe.com/products/acrobat/readstep.html

Patient Name

* Date*

Email address:

Primary Physician:

* Phone*

1. Describe your main problem / diagnosis.

2. Did you have any injections on your last visit?

* If yes, please check all that apply below:

Epidural Sacral Joint Facet Joint Trigger Point
Other Nerve Block Injections

3. Were any medications started on your last visit?

* If yes, please complete below:


Name	Dosage	Times per day

4. Were any medication dosages changed on your last visit?

* If yes, please complete below:


Name	old Dosage	new Dosage	Times per day

5. Please LIST ALL of your current pain medications and the doctors that prescribe them.

DO NOT WRITE "SAME AS BEFORE"

Name	Dosage	Times per day	Prescribing doctor

Have your symptoms been helped? Please explain below:

6. Rate of Relief.

7. For your own health and safety, PLEASE list all other medications you are taking, including non-prescription:

DO NOT WRITE "SAME AS BEFORE"

Name	Dosage	Times per day

8. Please check any conditions you have experienced since your last appointment:

chills night sweats fever easy bleeding rash bruising recent changes in vision smell hearing or taste dizziness
shortness of breath sputum wheezing cough chest pain
feet swelling palpitations nausea diarrhea indigestion
bloody or dark stools vomiting abdominal pain
unable to control bowel or bladder rushing to urinate frequent urination muscle cramps joint pain / swelling attack of weakness
morning stiffness poor appetite numbness / tingling in feet crying spells numbness / tingling in hands convulsions headache

9. Select the numbers below that best describe how pain has interfered with your daily functions this past week.

10. Please list any side effects that you feel may have been caused by your pain medicine.

Side Effects	When	Doctor's Instruction	What you did about them

©2000 - 2006 Gulf Coast Pain Management
Dr. Lynne C. Columbus
3890 Tampa Road Suite 308
Morton Plant Mease East Lake Outpatient Center
Palm Harbor, Florida 34684

Phone: (727) 789-0891 Fax: (727) 789-1570
E-mail: info@gulfcoastpain.com

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