Follow-up Visit Form

Tracks how the patient has progressed between appointments: pain location and intensity, response to medications and injections, and any medical developments since the last visit. Nursing staff get a complete picture before the consultation.

Use this template

Are you the patient?

Yes No Not sure

If you're answering for an adult, please let us know who you are. Answer all questions on behalf of the patient; whenever you see "you", answer about the patient.

First and last name of the person completing this information on behalf of the patient

Nombre

Apellido

Patient's Name

Nombre

Apellido

Patient's Date of Birth

Today's Date

Enter the date (or approximate date) of your most recent COVID-19 vaccine dose

Reason for Your Visit

Routine follow-up Medication refill New pain Injection follow-up Test results review Other

What is the name and address of your preferred pharmacy?

Location of the pain that you are here for

Are any of these pains new since your last visit?

Yes No Not sure

If yes, please explain

Where does your pain radiate into?

What word best describes the frequency of your pain?

When is your pain worse?

In the morning In the evening During sleep With activity At rest With weather changes

Describe the severity of your pain at its worst (0 as no pain and 10 as the worst pain you can imagine)

0-2 (mild) 3-4 (low moderate) 5-6 (moderate) 7-8 (severe) 9-10 (unbearable)

Describe the severity of your pain today (0 as no pain and 10 as the worst pain you can imagine)

0-2 (mild) 3-4 (low moderate) 5-6 (moderate) 7-8 (severe) 9-10 (unbearable)

Are you currently treating your pain with any of the following conservative treatments?

What are you taking for your pain?

How much relief has pain medication provided?

Complete relief Significant relief Moderate relief Mild relief No relief

My medications help improve my functioning and quality of life.

Which aspects of functioning and quality of life do your medications improve? (select all that apply)

Mark the following medicine side-effects you are experiencing, if any

Do you have full control of your bladder and bowels?

Yes No Not sure

Which of the following activities does your pain significantly interfere with?

Have you visited the emergency room since your last visit?

Yes No Not sure

Have you had any X-rays, MRIs, CT scans since your last visit?

Yes No Not sure

Have you had any operations or procedures since your last visit?

Yes No Not sure

Have you been diagnosed with any new medical problems since your last visit?

Yes No Not sure

Which option describes your pain relief produced by the last injection?

Complete relief Substantial relief Moderate relief Minimal relief No relief

Did the last injection result in functional improvement?

Yes No Not sure

For this site, how long was your pain relief and functional improvement achieved?

Less than 1 week 1 to 4 weeks 1 to 3 months 3 to 6 months Over 6 months

Have you continued with conservative therapy since the last injection?

Yes No Not sure

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