OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare
OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare
OT OASIS C FOLLOW-UP/RECERT - TriPoint Healthcare
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Patient Name_____________________________________________Date:_____/_____/_____<br />
7<br />
Barriers to Pain Control<br />
Culture Education Philosophy of caregiver Physical<br />
Emotional Spiritual Financial Other<br />
Pain Relief measures<br />
Rest Other<br />
Current Meds:<br />
Pain Relief Medications & Response:<br />
Effects of Pain Relief Measures ________<br />
Impact on Functional Activity:<br />
Location:<br />
Abdomen Arm Back Chest<br />
Generalized Head/Neck Leg Shoulder Other<br />
Patient Describes Pain as:<br />
Ache Burning Dull Sharp Stabbing Throbbing<br />
Pain Intensity Level Now: 0 01 02 03 04 05 06 07 08 09 10<br />
Pain Intensity at Worst: 0 01 02 03 04 05 06 07 08 09 10<br />
Pain Intensity at Best: 0 01 02 03 04 05 06 07 08 09 10<br />
Acceptable Level of Pain: 0 01 02 03 04 05 06 07 08 09 10
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