Painsandiego.files.wordpress.com

Name: ________________________________________ DOB: _______________DATE______________ PLEASE CIRCLE EACH MEDICATION YOU HAVE USED FOR PAIN OR HEADACHE MANAGEMENT
Analgesics
Heart/Blood Pressure Meds
Muscle relaxants
Anti-Inflammatories
Antidepressants
Anticonvulsants
Decongestant/
Anit-Nausea/
Antihistamine
Phenothiazines/
Sleeping Pills/
Neuroleptics
Tranquilizers
Antimigraine
Medications
Steroids
Other Medications used for pain control in the past
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ LIST ALL MEDICATION ALLERGIES
________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ LIST ALL MEDICATION ADVERSE EFFECTS
1. ______________________________________________________________________________________________ 2. ______________________________________________________________________________________________ 3. ______________________________________________________________________________________________ 4. ______________________________________________________________________________________________ 5. ______________________________________________________________________________________________ PLEASE LIST BELOW ALL MEDICATIONS YOU ARE USING NOW
Frequency you are actually using
1. ______________________________________________________________________________________________ 2. ______________________________________________________________________________________________ 4. ______________________________________________________________________________________________ 5. ______________________________________________________________________________________________ 6. ______________________________________________________________________________________________ 7. ______________________________________________________________________________________________ 8. ______________________________________________________________________________________________ 9. ______________________________________________________________________________________________ 10. _____________________________________________________________________________________________ 11. _____________________________________________________________________________________________ 12. _____________________________________________________________________________________________ 13. _____________________________________________________________________________________________ 14. _____________________________________________________________________________________________ 15. _____________________________________________________________________________________________ 16. _____________________________________________________________________________________________ 17. _____________________________________________________________________________________________ 18. _____________________________________________________________________________________________ 19. _____________________________________________________________________________________________ 20. _____________________________________________________________________________________________

Source: http://painsandiego.files.wordpress.com/2009/04/medications.pdf

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